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MODERN TREATMENT. THE MANAGEMENT OF 
DISEASE BY MEDICINAL AND NON-MEDICINAL 
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A TEXT-BOOK 



PRACTICAL THERAPEUTICS, 



WITH ESPECIAL REFERENCE TO THE 



APPLICATION OF REMEDIAL MEASURES TO DISEASE 



AND THEIR 



EMPLOYMENT UPON A RATIONAL BASIS. 



BY 

HOBART AMORY HARE, M.D., B.Sc, 

H 

PROFESSOR OF THERAPEUTICS, MATERIA MEDICA, AND DIAGNOSIS IN THE JEFFERSON 

MEDICAL COLLEGE OF PHILADELPHIA; PHYSICIAN TO THE JEFFERSON MEDICAL 

COLLEGE HOSPITAL; ONE-TIME CLINICAL PROFESSOR OF DISEASES OF 

CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON, 

U. S N. R. F. 



SEVENTEENTH EDITION 



ENLARGED, THOROUGHLY REVISED, AND LARGELY RE-WRITTEN. 
ILLUSTRATED WITH 145 ENGRAVINGS AND 6 PLATES. 




LEA & FEBIGER, 

PHILADELPHIA AND NEW YORK. 

1918. 






V 



\% 



\* 



The object of this book is to place the subject of treatment before the 
reader so that it may be applied at the bedside in a rational manner. 



Copyright, 1918, by Lea & Febiger. 



The use in this volume of certain portions of the text of the United States 
Pharmacopoeia is by virtue of permission received from the Board of Trustees of 
the United States Pharmacopceial Convention. The said Board of Trustees is not 
responsible for any inaccuracy nor for any errors in the statement of quantities or 
percentage strengths. 



'©CI.A503549 

SEP 25 Iblb 



.<-. 



PREFACE TO SEVENTEENTH EDITION. 



The preparation of the seventeenth edition of a book requires 
more care and judgment than the writing of the first if the author 
desires to have it represent things as they are and not as they have 
been. He must hold fast to that which is good and cast aside that 
which has become obsolete, but in doing this he must not permit 
his desire to accept the new to overcome respect for the old, if the 
old has the endorsement of long experience on the part of his fellows 
and himself. At the present time scientific investigation has all 
the enthusiasm of youth and little of the judgment of age, and its 
ievotees, who speedily win for themselves the honor which is due the 
riginal investigator, are prone to reach dogmatic conclusions and 
rithout hesitation assert that views heretofore accepted are falla- 
cious. Those who carefully follow medical literature know full well 
that very frequently the laboratory investigator is shown to be as 
liable to fallacy as the bedside student. All too frequently impelled 
by the enthusiasm which has produced a research, the clinician 
embraces the results as gospel truth and is disappointed in his sub- 
sequent experience and at finding that other investigators soon 
prove the first in error. Apt illustrations of these statements are 
seen in Ehrlich's early view that one large dose of salvarsan would 
cure syphilis, in the failure of Wright's hope that by the use of cal- 
cium salts we could increase the coagulability of the blood, and the 
increasing evidence that vaccine therapy, while useful, has a limited 
range of value. 

The original investigator is like a prospector who, going over new 
or old fields, brings back to the assayer nuggets which often prove of 
great value, but many times prove of little or no value, and it is the 
duty of the author of a book of this nature to be an assayer and not 
to consider that new substances are always better than old ones 
or that old ones have been overvalued. The bedside student of 
therapeutics should read and study the results of investigators and 
the investigators should be slow in showing disrespect for his long- 
established conclusions. In this edition the autho*r has endeavored 
to place before his students and readers facts from the laboratory 
and clinic in proper balance. It must be recalled that practical 
therapeutics will always be ahead of experimental therapeutics 
because thousands are practising the former and dealing with condi- 
tions of disease and a mere handful are working in the laboratory 

(v) 



VI PREFACE TO SEVENTEENTH EDITION. 

and using healthy men and animals in their studies. The last thirty 
years have done much to put hitherto empirical methods < upon a 
scientific basis, to develop new plans of treatment and, in the repeated 
revisions of this book, the author has tried to include most of them. 

The great war has greatly increased our knowledge concerning 
shock, emphasized the need of proper methods of intravenous injec- 
tion or of direct transfusion, and, therefore, greater consideration 
of the technique of these procedures is included than before. The 
use of Dakin's fluid and dichloramine-T by Carrel's methods and the 
treatment of burns by paraffine are discussed for the first time. 
The methods of prescribing a proper diet for the sick are described 
more in detail than formerly, particularly in respect to children and 
diabetics. Many important drugs heretofore made in Germany, or 
under German patents, are now made in this country and have been 
given names whereby they may be properly designated, as, for 
example, arsphenamine for salvarsan, and procaine for novocaine, 
and these changes have been included in the following pages. 

The present edition has required so many alterations and addi- 
tions that a large part of it has been reset in new type. 

As in the earlier editions, so in this, the author wishes to acknowledge 
the kindness of his friends who have revised articles dealing with sub- 
jects in which they are recognized authorities, namely, Dr. G. E. 
de Schweinitz, the articles on diseases of the eye; Dr. Edward Martin, 
those on venereal diseases, and Dr. Barton C. Hirst, those which 
touch upon the disorders of parturition or pregnancy. 

H. A. H. 
August, 1918, 

1801 Spruce Street, 
Philadelphia. 



CONTENTS 



PART I. 
General Therapeutical Considerations 17 

PART II. 
Drugs 63 

PART III. 

Remedial Measures other than Drugs 535 

Feeding the Sick . 639 

PART IV. 

Treatment of Diseases 655 

Index of Drugs and Remedial Measures ..... 945 
Index of Diseases and Remedies 975 



Jvii) 



Comparative Table showing the Strength of the More Important Pharma- 

copceial Substances and Preparations in the Preceding and in the 

Present Pharmacopoeia 



Title. 



Chief Constituent. 



U. S. P. 8th Revision. 



U. S. P. 9th Revision. 



Acidum Aceticum . 
Dilutum . 

Benzoicum . 

Boricum 

Hydriodicum Dilu- 
tum 

Hydrobromicum 
Dilutum 

Hydrochloricum 

Hydrochloricum 
Dilutum 

Hydrocyanicum 
Dilutum 

Hypophosphorosum 

Hypophosphorosum 

Dilutum 
Lacticum 



Nitricum 
Phosphoricum . 

Phosphoricum Dilu 

turn 
Salicylicum . 
Sulphuricum 

Aromaticum . 
Dilutum 
Trichloraceticum . 
Aconitum .... 



.Ether . . . 
Alcohol Dilutum 



Alumen Exsiccatum 

Ammonii Bromidum 
Carbonas . 

" Iodidum . 
Antimonii et Potassii Tar 

tras 
Aqua Ammonise 

" Fortior 

Argenti Nitras . 

" Fusus 
" Oxidum . 

Arseni Iodidum . 

Asafcetida .... 



Bismuthi et Ammonii 
Citras 
" Subnitras . 
Bromoformum . 
Caffeina Citrata 

Effer- 
yescens 
Calcii Bromidum 

Carbonas Prsecipi 
tatus 
Calcii Chloridum 

Calx 

Cannabis ' 

Cantharis ..'.'. 

Chloralum Hydratum 



Acetic Acid . 

Hydriodic Acid 
Hydrobromic Acid 
Hydrochloric 



Hydrocyanic " 

Hypophosphorous 

Acid 
Hypophosphorous 

Acid 
Lactic Acid . 



Nitric 
Phosphoric Acid 



Sulphuric 



Ether-soluble alka- 
loids of aconite 

Ethyl oxide . 
Alcohol . 



Ammonia 



Alcohol-soluble 
constituents 



Bismuth oxide 



Caffeine 



Cantharidi 



not less than 36.0 per cent. 

6.0 
no assay ...... 

not less than 99.8 per cent. 
" 10.0 

" 10.0 

" 31.9 
" 10.0 

" 2.0 

" 30.0 

" 10.0 

" 75.0 

of lactic acid without 

anhydrides 

not less than 68.0 per cent. 

" 85.0 

" 10.0 

no assay 

not less than 92.5 " 

" 20.0 

" 10.0 
no assay . .... 
not less than 0.5 per cent 
aconitine 

about 96 per cent. 

about 41.5 per cent, by 

weight 
about 48.9 per cent, by vol 

ume 
not less than 99.0 per cent. 

" 970 

yielding not less than 31.58 

per cent. NH 3 
not less than 97.0 per cent 
" 99.5 

" 10.0 
" 28.0 
" 99.9 
" 94.8 
" 99.8 
not less than 82.7 per cent 

iodine 
not less than 16.3 per cent. 

arsenic 
gum-resin — not less than 50 
per cent. 



from 46 to 50 per cent. 

not less than 80 per cent. . 

99 per cent 

no assay 

not less than 97.0 per cent. 

" 99.0 

not less than 99 per cent 

(anhydrous) 
not less than 90 per cent, 
no assay 



from 36.0 to 37.0 per cent. C2H4O2. 

5.7 to 6.3 
not less than 99.5 per cent. C7H6O2 
" 99.5 " H 3 B0 3 

from 9.5 to 10.5 per cent. HI. 



9.5 to 10.5 

31.0 to 33.0 
9.5 to 10.5 

1.9 to 2.1 

30.0 to 32.0 

9.5 to 10.5 



HBr. 

HC1. 
HC1. 

HCN. 

H3PO2. 
H3PO2. 



lactic acid and lactic anhydrides 

equivalent to from 85 to 90 per 

cent. CsHgOs. 

from 67.0 to 69.0 per cent. HNO3. 

" 85.0 to 88.0 " H3PO4. 

" 9.5 to 10.5 " H3PO4. 

not less than 99.3 " CyHeOs. 

from 93.0 to 95.0 " H2SO4. 

" 19.0 to 21.0 " H2SO4. 

" 9.5 to 10.5 " H2SO4. 

not less than 99 per cent. C2HO2CI3. 
not less than 0.5 per cent, ether- 
soluble alkaloids; biological 
assay recommended, 
from 95.5 to 97.5 per cent.(C 2 H s )20. 
from 41.0 to 42.0 per cent, by 

weight, 
from 48.4 to 49.5 per cent, by vol- 
ume, C2H5CH. 
not less than 96.5 per cent. AIK 

(S0 4 ) 2 or AINH 4 (S04) 2 . 
not less than 98.5 per cent. NHiBr. 
yielding from 30 to 32 per cent. 

NH 3 . 
not less than 99.0 per cent. NH4I. 
" 98.5 
K(SbO)C4H 4 06-BH 2 0. 
from 9.5 to 10.5 per cent. NH3. 
" 27.0 to 29.0 " NH 3 . 
not less than 99.8 per cent. AgNC-3. 
" 94.5 " AgN0 3 .* 
" 99.6 " AgaO. 



99.0 



Asl 3 . 



gum-resin — not less than 60 per 
cent, alcohol-soluble constit- 
uents. 

powder — not less than 50 per cent, 
of alcohol-soluble constituents. 

from 46 to 52 per cent. Bi203. 

not less than 79 per cent. Ei 2 03. 
about 96 per cent. CHBr 3 . 
not less than 48.0 per cent. 

a L g 



" 84.0 " CaBr 2 
(hydrated form), 
not less than 98 per cent. CaC0 3 . 

not less than 75 per cent. CaCb. 

(hydrated form), 
not less than 95 per cent. CaO. 
biological assay required, 
not less than 0.6 per cent, of can- 

tharidin. 
not less than 99.5 per cent. 

C2HCI3O +H2O. 



Comparative Table showing the Strength of the More Important Pharma- 
copoeial Substances and Preparations — Continued. 



Title. 



Chief Constituent 



U. S. P. 8th Revision. 



U. S. P. 9th Revision. 



Chromii Trioxidum . 
Cinchona .... 

Codeinse Phosphas . 

Creta Prseparata 
Cupri Sulphas 

Digitalis 

Emplastrum Belladonna? 

Extractum Belladonna? 
Foliorum 
Cannabis 
Colchici Cormi 

Hyoscyami . 

Nucis Vomicae 

Opii . . . 

Physostigmatis 

Stramonii 

Ferri Chloridum 

et Ammonii Citras 
et Quinina? " 

Sulphas .... 

Sulphas Exsiccatus 
Fluidextractum Aconiti 

Belladonna? Radicis 



Cannabis 
Cinchona? 



Colchici Seminis 

Digitalis 
Guarana? 



Hydrastis 

Hyoscyami . 

Ipecacuanha? 

Nucis Vomica? . 

Pilocarpi 

Scilla? . . . 
Glyceritum Hydrastis 

Guarana .... 



Cinchona alkaloid 



not less than 99.0 per cent. 

not less than 5.0 per cent, 
total anhydrous cin- 
chona alkaloids and at 
least 4 per cent, anhy- 
drous ether-soluble alka- 
loids 

no assay 



than 



.5 per cent 



Alkaloids from bel 
ladonna leaves 

Alkaloids from bel 
ladonna leaves 

Colchicine 

Alkaloids from hy 
oscyamus 

Alkaloids from nux 
vomica 

Anhydrous mor- 
phine 

Alkaloids from 

physostigma 

Alkaloids from 

stramonium 

Iron .... 

" and quinine 



Ether-soluble alka- 
loids from aco 
nite 

Alkaloids from bel 
ladonna root 



Cinchona alkaloids 



Colchicine 



Caffeine 



Ether-soluble alka 
loids from hy 
drastis 

Alkaloids from hy 
oscyamus 

Ether-soluble alka 

loids from ipe 

cac 
Alkaloids from nux 

vomica 
Alkaloids from 

pilocarpus 

Ether-soluble alka- 
loids from hy- 
drastis 

Caffeine . 



leaves from plants of second 
year's growth, at com 
mencement of flowering 

from 0.3S to 0.42 per cent. 

1.4 par cent, mydriatic alka- 
loids 

no assay 

1.4 per cent 



0.3 per cent, mydriatic alka- 
loids 
5.0 per cent, strychnine 

20.0 per cent, crystallized 

morphine 
2 per cent, ether-soluble 

alkaloids 
1 per cent, mydriatic alka 

loids 
22 per cent 



16 

not less than 13.5 per cent 
iron and 11.5 per cent 
dried quinine 

not less than 99.5 per cent. 



100 mils, contains 0.4 Gm 
of aconitine 



100 mils, contains 0.4 Gm 
mydriatic alkaloids 

no assay 

100 mils, contains 4 Gm. of 

anhydrous ether-soluble 

alkaloids 
100 mils, contains 0.4 Gm. 

colchicine 

no assay 

100 mils, contains 3.5 Gm 

of alkaloids from guar 

ana 
100 mils, contains 2 Gm. hy 

drastine 

100 mils, contains 0.075 Gm 
100 mils, contains 1.5 Gm 



100 mils, contains 1 Gm 

strychnine 
100 mils, contains 0.4 Gm 



Hydrargyri Chloridur 
Mite 



not less than 3.5 per cent 

alkaloidal principles 
not less than 99.5 per cent. 



not less than 95.0 per cent. Cr03. 



not less than 5.0 per cent, total 
alkaloids. 



not less than 67 per cent, anhy- 
drous codeine. 

not less than 97 per cent. CaCOj. 

from 62.97 to 66.79 per cent, anhy- 
drous CuS04 (not less than 
98.5 per cent. CuS04+5H 2 0). 

biological assay recommended. 



from 0.35 to 0.40 per cent, of alka- 
loids from belladonna leaves 

from 1.18 to 1.32 per cent, of alka- 
loids from belladonna leaves. 

biological assay required. 

from 1.25 to 1.55 per cent, of col- 
chicine. 

from 0.22 to 0.28 per cent, of the 
alkaloids from hyoscyamus. 

from 15.2 to 16.8 per cent, of alka- 
loids from nux vomica. 

from 19.5 to 20.5 per cent, of an- 
hydrous morphine. 

from 1.7 to 2.3 per cent, of the 
alkaloids from physostigma. 

from 0.9 to 1.1 per cent, of the 
alkaloids from stramonium. 

corresponding to 20 per cent. Fe. 

" to 16 to 18 per cent. Fe. 

" " 11.5 to 13 per cent. 

Fe and not less than 11.5 per 

cent, anhydrous quinine. 

from 54.36 to 57.07 per cent, anhy- 
drous FeS04 (not less than 99.5 
per cent. FeS04-|-7H20). 

not less than 80 per cent, anhy- 
drous FeS04. 

100 mils, contains 0.45 to 0.55 Gm. 
of the ether-soluble alkaloids 
of aconite; biological assay 
recommended. 

100 mils, contains 0.405 to 0.495 
Gm. of the alkaloids from bella- 
donna root. 

biological assay required. 

100 mils, contains 4 to 5 Gm. of the 
alkaloids from cinchona. 

100 mils, contains 0.36 to 0.44 Gm. 

of colchicine, 
biological assay recommended. 
100 mils, contains 3.6 to 4.4 Gm. 

of caffeine. 

100 mils, contains 1.8 to 2.2 Gm. 
of the ether-soluble alkaloids. 

100 mils, contains 0.055 to 0.075 
Gm. of the alkaloids from hyos- 
cyamus. 

100 mils, contains 1.8 to 2.2 Gm. 
of the ether-soluble alkaloids 
from ipecac. 

100 mils, contains 2.37 to 2 03 Gm. 
of alkaloids from nux vomica. 

100 mils, contains 0.55 to 0.65 Gm. 
of the alkaloids from pilocarpus. 

biological assay recommended. 

100 mils, contains 1.12 to 1.37 Gm. 
of the ether-soluble alkaloids 
from hydrastis. 

not less than 4 per cent, of caffeine. 

not less than 99.6 per cent. HgCl. 



Comparative Table showing the Strength of the More Important Pharma- 
copceial Substances and Preparations— Continued. 



Chief Constituent. U. S. P. 8th Revision. 



U. S. P. 9th Revision. 



Hydrargyri Iodidum 

Flavum 
Rubrum 
Hydrargyrum 

cum Creta . 
Hyoseyamus 

Iodum 

Jalap 



Linimentum Camphorse 

Liquor Acidi Arsenosi . 

Arseni et Hydrargyri 

Iodidi 
Ferri Chloridi . 

Subsulphatis 

Tersulphatis . 

Iodi Compositus 
Magnesii Citratis . 

Plumbi Subacetatis 

Potassii Arsenitis . 



Hydroxidi . 
Soda? Chlorinatse 
Sodii Arsenatis . ! 

Hydroxidi . 
Zinei Chloridi 
Lithium Bromidum 

Magnesii Carbonas . 



Mercury . 
Alkaloids from hy- 
oseyamus 

Resins of jalap . 



Camphor 

Arsenic trioxide . 

J 

Ferric Chloride . 

Basic ferric sul- 
phate 

Normal ferric sul- 
phate 

Iodine . . A 

Magnesium citrate 

Lead subacetate 

Potassium arsenite 



" hydroxide 
Available chlorine 
Sodium arsenate 



not less than 99.5 per cent. 



" 99.9 

38 per cent 

not less than 0.08 per cent. 



not less than 99.0 per cent. Hgl. 

" 99.0 " Hgl 2 . 
" 99.5 " Hg. 
from 37 to 39 per cent. Hg. 
not less than 0.065 per cent, of the 

alkaloids from hyoseyamus. 
99.5 per cent, iodine. 

total 



99 per cent. 

not less than 7 per cent, totalj not less than 7 per cent 

resin, of which not morel resins of jalap. 

than 15 per cent, should 

be soluble in ether 
20 per cent ! from 19.5 to 20.5 per cent, of cam- 
phor, 
corresponding to 1 per cent, corresponding to 0.975 to 1.025 

per cent. AS2O3. 
1 per cent, arsenous iodide from 0.95 to 1.05 per cent. Asi3. 
1 " mercuric iodide ! " 0.95 to 1.05 " Hgl2. 
corresponding to 10 per corresponding to 10 to 11 per cent. 

cent, of iron Fe. 

corresponding to not less; corresponding to 13 to 1-4 per cent. 



of 



than 13.57 per cent 

iron 
corresponding to not less 

than 10 per cent, of iron 
5 per cent, iodine . 
10 " potassium iodide 
no assay . 



Fe. 



Oxidum 



Ponderosum 
Sulphas . 



Maltum 

Massa Ferri Carbonatis 

Hydrargyri . 
Methylis Salicylas . 

Nux Vomica .... 




corresponding to 10 to 11 per cent. 

Fe. 
from 4.8 to 5.2 per cent, iodine. 

" 9.8 to 10.2 " KI. 
corresponding to not less than 1.5 
Gm. MgO in 100 mils, 
not less than 25 per cent, of lead subacetate corresponding to 
lead subacetate not less than 18 per cent. Pb. 

potassium arsenite corre-, potassium arsenite corresponding 



Mercury 



Oleum Cajuputi 
Cari . . 



Caryophylli 

Cassia? (Oleum Cin- 

namomi U. S. P. 

VIII) 
Eucalypti 

Mentha? Piperitae . 



Alkaloids from nux 

vomica . 
Cineol 
Carvone . 

Eugenol . 
Cinnamic aldehyde 



Eucalyptol 
Menthol . 



sponding to 1 per cent 
of arsenic trioxide 

about 5 per cent. . 

at least 2.4 per cent. . 

not less than 1 per cent, ex- 
siccated salt 

about 5 per cent. . 

"50 " . . . 



magnesium oxide 

not less than 96 per cent. . 

same as magnesii oxidum . 
not less than 99.7 per cent 
crystallized salt 

no assay 

33 per cent 

no assay 

not less than 1.25 per cent. 

strychnine 
not less than 55 per cent, 
no assay 

not less than 80 per cent. . 



Opii Pulv: 
Opium 



Viridis . 



Carvone . 
Morphine 



to 0.975 to 1.025 per cent. 
AS2O3. 
not less than 4.5 per cent. KOH. 
" 25 

from 0.975 to 1.025 per cent. 
Na 2 HAs04. 

not less than 4.5 per cent. NaOH. 
48.5 to 52 per cent, 
not less than 97 per cent.! not less than S5 per cent. LiBr. 

when dried 

magnesium carbonate corre- magnesium carbonate and hydrox- 

sponding to not less ide corresponding to not less 

than 3S.4 per cent, of than 39.2 per cent. MgO and 

not more than 0.8 per cent. 

CaO. 

not less than 96 per cent. MgO, 
nor more than 2 per cent. CaO. 

same as magnesii oxidum. 

from 4S.59 to 53.45 per cent, anhy- 
drous MgS04 (not less than 
99.5 per cent. MgS0 4 + 7H2O). 

capable of converting 5 times its 
weight of starch into sugars. 

not less than 35 per cent. FeCOs. 

from 32 to 34 per cent, of Hg. 

not less than 98 per cent. 
CH3C7H5O3. 

not less than 2.5 per cent, of the 
alkaloids of nux vomica. 

no assay. 

not less than 50 per cent, of car- 
vone. 

not less than 82 per cent, of eugenol 

not less than 80 per cent, of cinna- 
mic aldehyde. 



" 50 

not less than 6 per cent, of 
esters calculated as men- 
thyl acetate and not less 
than 50 per cent, of total 
menthol 

no assay 

12 to 12.5 per cent, crystal- 
lized morphine 

not less than 9 per cent, 
crystallized morphine 



not less than 70 per cent, of (euca- 
lyptol) cineol. 

not less than 5 per cent, of esters 
calculated as C10H19C2H3O2 
and not less than 50 per cent, 
of CioH 19 OH. 

not less than 43 per cent. 

10 to 10.5 per cent, anhydrous 
morphine. 

not less than 9.5 per cent, anhy- 
drous morphine. 



Comparative Table showing the Strength of the More Important Pharma- 
copceial Substances and Preparations— Continued. 



Title. 


Chief Constituent. 


U. S. P. 8th Revision. 


U. S. P. 9th Revision. 


Opium Deodoratum 


Morphine 


12 to 12.5 per cent, crys- 


10 to 10.5 per cent, anhydrous 






tallized morphine 


morphine. 


Granulatum 


" 


12 to 12.5 per cent, crys- 


10 to 10.5 per cent, anhydrous 






tallized morphine 


morphine. 


Phenol . . . . . 




not less than 96.0 per cent. 


not less than 97 per cent. C6H5OH. 


Liquefactum 




" " 86.4 " 


" 87 " CeHsOH. 




phenol 
not less than 99.5 per cent. 




Phosphorus .... 




no assay. 


Pilocarpus .... 


Alkaloids from 


0.5 per cent 


0.6 per cent, of the alkaloids from 




pilocarpus 




pilocarpus. 


Pilulas Ferri Carbonatis 




no assay 


each pill contains not less than 
0.06 Gm. FeCOs. 








Plumbi Acetas . 




not less than 99.5 per cent. 


from 85.31 to 89.57 per cent, anhy- 
drous Pb(C2H302)2 (not less 
than 99.5 per cent. Pb(C2H 3 2 )2 
+3H 2 0). 

not less than 3.0 per cent, of resin. 


Podophyllum 


Resin of podophyl- 
lum 


no assay 


Potassii Acetas . 


not less than 98.0 per cent. 
" 99.0 


" " 99.0 " KC2H3O2. 


Bitartras 




" 99.5 " KHC4H4O6. 


Bromidum . 




" 970 


not less than 98.5 per cent. KBr. 


Carbonas . . . 




" 98.0 


" 99.0 " K2CO3. 


et Sodii Tartras 




" 99.0 " 


from 73.71 to 77.39 per cent, of an- 








hydrous KNaC4H406 (not less 








than 99 per cent. KNaC4H 4 OG 








+4H 2 0). 


Pulvis Effervescens Com- 




no assay 


from 23 to 27 per cent, sodium bi- 
carbonate; from 73 to 78 per 


positus .... 










cent, potassium and sodium 








tartrate. 


Resorcinol 




..... 


not less than 99.5 per cent. CgH4 
(OH) 2 . 


Scilla 




" 


biological assay recommended. 


Sodii Acetas .... 




not less than 99.5 per cent. 


from 59.97 to 62.96 per cent, anhy- 
drous NaC2H30-2 (not less than 
99.5 per cent. NaC 2 H 3 02 + 
3H 2 0). 


Arsenas .... 




" 98.0 


from 58.98 to 61.92 per cent, anhy- 
drous Na2HAs04 (not less than 
99 per cent. Na 2 HAs04+7H 2 0). 


Boras .... 




" 99.0 


from 52.32 to 54.92 per cent, anhy- 
drous Na2B407 (not less than 
99 per cent. Na 2 B 4 O7+10H 2 O). 


Bromidum . 




" 97.0 


not less than 98.5 per cent. NaBr. 


Citras .... 




" 970 


" 98.0 
Na3C6H 5 07+2H 2 0. 


Iodidum 




" 98.0 


not less than 99.0 per cent. Nal. 


Nitris .... 




" 90.0 


" 95.0 " NaN0 2 . 


Phenolsulphonas 




" 99.0 


from 83.64 to 87.82 per cent, anhy- 








drous NaCeHsO.SOs (not less 








than 99 per cent. NaCeEUO.SOs 








+2H2O). 


Phosphas 




" 99.0 


from 39.25 to 44 per cent, anhy- 
drous Na2HPC"4 (not less than 
99 per cent. Na 2 HP04+12H 2 0). 


Exsiccatus 




" 99.0 
" 99.0 


not less than 98 per cent. Na2HPC>4. 


Sulphas .... 




from 43.64 to 48 per cent, anhy- 








drous Na 2 S04 (not less than 99 








per cent. Na 2 SO4+10H 2 O). 


Thiosulphas 




" 98.0 


from 63.07 to 67.48 per cent, anhy- 






drous Na 2 S 2 0-3 (not less than 99 








per cent. Na 2 S 2 03+5H 2 0). 


Spiritus iEtheris Nitrosi 


Ethyl nitrite 


" 4.0 


from 3.5 to 4.5 per cent. C 2 H 5 N0 2 . 


Glycerylis Nitratis 


Glyceryl trinitrate 


1 per cent 


from l.Oto 1.1 percent. CsHsCNC^s. 


Strontii Bromidum ; 




not less than 97.0 per cent. 


not less than 98 per cent. SrBr 2 + 


Iodidum 




" 98.0 


6H 2 0. 
not less than 99 per cent. Srl 2 -|- 
6H2O. 


Salicylas 




" 98.5 


not less than 99 per cent. 
Sr(C7H 5 03) 2 +2H 2 0. 


Strophanthus 




no assay 


biological assay recommended. 


Sulphur Sublimatum 




not less than 99 per cent. . 


not less than 99.5 per cent, sulphur. 


Suprarenalum Siccum 




no assay 


from 0.4 to 0.6 per cent, epineph- 


(Glandulae Supra- 






rine; biological assay recom- 


renales Sicca? U. S. P. 






mended. 


VIII) 








Syrupus Acidi Hydriodici 


Hydriodic Acid . 


about 1 per cent, or about 


100 mils, contains 1.3 to 1.45 Gm. 






1.19 Gm. in 100 mils. 


HI. 


Ferri Iodidi 


Ferrous Iodide . about 5 per cent, or about 
6.74 Gm. in 100 mils. 


from 4.75 to 5.25 per cent. Fel 2 . 


Thymolis Iodidum . 


Iodine . . .45 per cent 


not less than 43 per cent, iodine. 



Comparative Table showing the Strength of the More Important Pharma- 
copceial Substances and Preparations — Continued. 



Title. 


Chief Constituent. 


U. S. P. 8th Revision. 


U. S. P. 9th Revision. 


Thyroideum Siccum 


Iodine 


no assay ..... 


from 0.17 to 0.23 per cent, iodine 


(Glandulse Thyroideae 






in thyroid combination. 


Siccse U. S. P. VIII) 








Tinctura Aconiti 


Ether-soluble alka- 


100 mils, contains 0.045 Gm. 


100 mils, contains 0.045 to 0.055 




loids from aco- 


aconitine 


Gm. of the ether-soluble alka- 




nite 




loids from aconite; biological 
assay recommended. 


Belladonnee Foliorum 


Alkaloids from bel- 


100 mils, contains 0.03 Gm. 


100 mils, contains 0.027 to 0.033 




ladonna leaves 




Gm. of the alkaloids from bella- 
donna leaves. 


Cannabis 




no assay ..... 


biological assay required. 


Cinchonas 


Alkaloids from cin- 


100 mils, contains 0.75 Gm. 


100 mils, contains 9.9 to 1.1 Gm. 




chona 


anhydrous ether-soluble 
alkaloids 


of the alkaloids from cinchona. 


Composita 


Alkaloids from cin- 


no assay 


100 mils, contains 0.45 to 0.55 Gm. 




chona 




of the alkaloids from cinchona. 


Colchici Seminis 


Colchicine 


100 mils, contains 0.04 Gm. 


100 mils, contains 0.036 to 0.044 
Gm. of colchicine. 


Digitalis 




no assay 


biological assay recommended. 


Ferri Chloridi . 


Ferric Chloride . 


13.28 per cent, anhydrous 


about 13 per cent. FeCl3, corre- 






salt, corresponding to 


sponding to not less than 4.48 






4.6 (4.58) per cent, met- 


per cent. Fe. 






allic iron 




Hydrastis . 


Ether-soluble alka- 


100 mils, contains 0.4 Gm. 


100 mils, contains 0.36 to 0.44 Gm. 




loids from hy- 


hydrastine 


of the ether-soluble alkaloids 




drastis 




from hydrastis. 


Hyoscyami . 


Alkaloids from hy- 


100 mils, contains 0.007 Gm. 


100 mils, contains 0.0055 to 0.0075 




oscyamus 


mydriatic alkaloids 


Gm. of the alkaloids from hyos- 


Iodi .-.'.. . 




100 mils, contains 7 Gm. of 


cyamus. 
100 mils, contains 6.5 to 7.5 Gm. of 






iodine and 5 Gm. of 


iodine and 4.5 to 5.5 Gm. KI. 






potassium iodide 




Nucis Vomicae . 


Alkaloids from nux 


100 mils, contains 0.1 Gm. 


100 mils, contains 0.237 to 0.263 




vomica 


strychnine 


Gm. of the alkaloids of nux 
vomica. 


Opii 


Morphine 


100 mils, contains 1.2 to 1.25 


100 mils, contains 0.95 to 1.05 Gm. 






Gm. crystallized mor- 
phine 
100 mils, contains 1.2 to 1.25 


anhydrous morphine. 


Deodorati . 


« 


100 mils, contains 0.95 to 1.05 Gm. 






Gm. crystallized mor- 


anhydrous morphine. 






phine 




Physostigmatis 


Alkaloids from 


100 mils, contains 0.014 Gm. 


100 mils, contains 0.013 to 0.017 




physostigma 


ether-soluble alkaloids 


Gm. of the alkaloids from phy- 
sostigma. 
biological assay recommended. 


Scillse .... 




no assay 


Stramonii . 


Alkaloids from 


100 mils, contains 0.025 Gm. 


100 mils, contains 0.0225 to 0.0275 




stramonium 


mydriatic alkaloids 


Gm. of the alkaloids from stra- 
monium. 


Strophanthi 




no assay ..... 


biological assay recommended. 


Unguentum Hydrargyri 


Mercury . 


not less than 49 per cent. 


from 49 to 51 per cent. Hg. 


Dilutum 


" ... 


about 33 per cent. . 


" 29 to 31 " Hg. 


Phenolis 


Phenol . ! . 


3 per cent 


about 2 per cent. 


Zinci Acetas .... 




not less than 99.5 per cent. 


from 83.16 to 87.32 per cent, anhy- 
drous Zn(C2H 3 0-2)2 (not less 
than 99.5 per cent. Zn(C2Hi02j2 
4-2H20). 

corresponding to not less than 68 
per cent. ZnO. 


Carbonas Praecipita- 




corresponding to not less 
than 72 per cent, zinc 
oxide 


tus 




Chloridum . 




not less than 99.5 per cent. 


not less than 95. per cent. Z11CI2. 


Phenolsulphonas 




" 99.5 " 


from 73.7 to 77.4 per cent, anhy- 
drous Zn(C6HsO.S0 3 )2 (not 














less than 99.5 per cent. Zn 








(C6H 5 O.S03)2+8H 2 0). 


Stearas .... 




no assay ..... 


corresponding to 13 to 15.5 per 
cent. ZnO. 


Sulphas .... 




"not less than 99.5 per cent. 


from 55.86 to 58.65 per cent, anhy- 
drous ZnSO-t (not less than 99.5 
per cent. ZnS04+7H 2 0.) 



DRUGS WITHDRAWN FROM THE BRITISH PHARMACOPOEIA. 



The General Medical Council of Great Britain has issued an official 
announcement to doctors and chemists, which alters the 'British 
Pharmacopoeia, 1914. Until further notice there are withdrawn from 
the Pharmacopoeia, the medicines and compounds, and the directions 
for preparing them, set forth in the following schedule, the medicines 
and compounds ceasing to be included among official preparations 
of The British Pharmacopoeia, 1914, until legal order respecting them 
is made: 

All confections, except confectio piper is, confectio rosse gallicse. 

All glycerina, except glycerinum. 

All misturse, except mistura cretse, mistura ferri composita, mistura 
olei ricini. 

All syrupi, except syrupus, syrupus chloral, syrupus codeine phos- 
phatis, syrupus ferri iodidi, syrupus ferri phosphatis cum quinina et 
strychnina, syrupus glucosi. 

All trochisci, except trochiscus kramerise et cocainee, trochiscus 
morphina?. trochiscus morphinee et ipecacuanha?. 

All caffeinse citras effervescens, decoctum aloes compositum, extrac- 
tum gossypii, radicis corticis liquidum, linimentum potassi iodidi cum 
sapone, liquor calcis saccharatus, magnesii sulphas effervescens, mel 
boracis, pulvis amygdalae compositus, pulvis glycyrrhizse compositus, 
pulvis tragacanthse compositus, sodii citrotartras effervescens, sup- 
positoria glycerini, tinctura cardamomi composita, tinctura kino, 
tinctura pruni virginianse, tinctura rhei composita, tinctura sennse 
composita, unguentum iodi. 



(xiv) 



PART I. 

GENERAL THERAPEUTICAL CONSIDERATIONS. 



Before entering into a study of the action of drugs upon the 
living body, it is necessary that the student should possess a clear idea 
that the word " therapeutics " means the treatment of disease, that 
he should comprehend fully the reason why resort is had to remedial 
measures, and, more important than all, that he should grasp the 
limitations which govern the administration of remedies. He should 
never forget, as student and practitioner, the following rules : 

When called to guide a patient through an illness the physician should 
be constantly a watchman, and a therapeutist only when necessity arises. 

A good physician is one who, having pure drugs, knows when to use 
them, how to use them, and, equally important, when not to use them. 

Any drug which has the power to do good when rightly used, has 
the power to do harm if wrongly used. 

When a physician gives a drug and the patient improves, care should 
be taken not to ascribe all the good results to the remedy employed. 
Nature must be given credit for a large part of the improvement. 

In the sixteenth century Ambroise Pare, the father of modern surgery, 
wrote, "I dressed him; God cured him." 

There are those who deride the use of drugs in the alleviation 
and cure of disease. Such persons have never used them or have 
used them improperly. The man who does not believe in the proper 
use of remedies lacks the very keystone of the arch upon which all 
medical investigation rests, for the ultimate aim and object of all 
medical thought and effort is the cure or alleviation of disease. 
Like every other thing requiring a thorough knowledge of its com- 
ponent parts, methods of treatment are often much abused by the 
careless and ignorant, but are a power for good in the hand of the 
properly educated physician. Further than this, therapeutics is the 
only universally used part of medicine, for each and every branch 
must resort to it. 

The first duty of the physician when called to a case of illness is to 
reach a diagnosis as to the cause of the ailment, and not until he has 
formed a definite idea as to the condition which confronts him should 
he prescribe any medicinal agent. In certain cases where the symp- 
toms are severe or indicative of immediate danger it may be necessary 
to give relief by the use of temporary remedies, not only to save life, 
but also to remove symptoms which, because of their severity, mask the 
2 (17) 



18 GENERAL THERAPEUTICAL CONSIDERATIONS. 

condition so that a diagnosis is impossible. Thus, a patient may be 
found in collapse or in a state of syncope. The cause of this state 
may be obscure, but the pulse, heart-sounds, and respiratory action 
may indicate the need of immediate stimulation. In another instance 
agonizing pain, as that due to a crisis in locomotor ataxia, or renal or 
hepatic colic, may require a hypodermic injection of morphine as 
soon as the physician assures himself that the pain complained of is 
genuine. In other instances the case may be so obscure that several 
days of careful study may be necessary to reach a correct diagnosis, 
and during this time palliative remedies may be required. 

Before ordering a drug or method of treatment the physician should 
have a clear conception of what he is trying to accomplish. No 
remedy should be given unless there is a distinct indication for its use. 
The old-fashioned " shot-gun " prescription, containing many ingredi- 
ents, one or more of which might hit the mark, should be supplanted 
by the small-calibre rifle-ball sent with directness at the condition to 
be relieved. 

Having decided upon the remedy indicated, the physician must 
next determine the dose required. This latter decision is almost as 
important as the first, for very often an error in dosage will cause 
failure of the remedy. A large part of the therapeutic skill of the 
physician consists in fitting the dose to the needs of his patient. 

In the treatment of all forms of disease the physician must never 
forget the following influential factors in the case, which are often of 
greater importance than the measures devoted to the treatment of the 
disease itself: 

1. The maintenance of vital resistance by proper feeding. 

2. The elimination of effete materials by the kidneys, bowels, 
and skin. 

3. The relief of annoying symptoms which sap the patient's vitality 
and often obscure the true state of the system. 

4. That sufficient physical and mental rest and sleep are obtained 
if possible. 

1. That the proper use of food in both acute and chronic illness is of 
great importance is not only manifest, but it has been proved by 
scientific investigation that lack of food often prevents the system 
from successfully combating the entrance and growth of infecting 
micro-organisms. The patient who has a greatly lowered vital resist- 
ance not only suffers from the effects of the particular disease by 
which he has been attacked, but not rarely dies from the growth of 
other micro-organisms which find him a fair mark for their attacks, 
thereby producing what Flexner has well called " terminal infections," 
and causing Osier to say that "a man rarely dies of the disease from 
which he is suffering," meaning by this that though he may be ill of a 
specific infection, other germs really produce the fatal issue. Care in 
feeding is therefore never to be ignored, and the various ways of feeding 
and preparing foods must be carefully studied. (See Part III.) 



GENERAL THERAPEUTICAL CONSIDERATIONS. 19 

2. It would seem hardly necessary to insist on the importance of 
maintaining the active elimination of impurities from theT)ody were 
it not that so little attention is paid by some physicians to these func- 
tions. In all infectious diseases the kidneys are required not only to 
eliminate the ordinary waste products of the body, which usually 
escape in this way, but in addition the increased waste produced by 
the fever and the poisons produced directly and indirectly by the 
growth of the invading micro-organisms. It is essential therefore that 
the patient shall pass urine in sufficient amount to carry off these sub- 
stances, and this result often may be obtained by giving plenty of 
water to drink and increasing diuresis by the use of sweet spirit of 
nitre and citrate or acetate of potassium. Nor is it sufficient to 
determine that the quantity of urine is normal. Repeated esti- 
mations of the solids should be made in all serious cases, to ascertain 
whether the eliminating function of the kidney is active, for some- 
times the flow of urine is sufficient, but the quantity of urinary 
solids is far below what it should be. Not rarely in disease, and 
even in apparent health, the patient states that his bowels have 
moved daily, and the physician is content with this report with- 
out making inquiries as to the quantity of the feces or whether 
the quantity is adequate in regard to the amount of food ingested. 
Even when the bowels are moved daily we may find after some 
days that there has been a partial retention of fecal matter, so 
that the colon becomes filled with feces. Sometimes moderate diar- 
rhea is an effort of nature to eliminate poisons, and is to be regarded 
as an aid to the patient, and not to be arrested by constipating 
remedies. It is also to be recalled that one of the functions of 
the liver is the elimination and destruction of toxic materials, and 
therefore the use of a cholagogue not only unloads the bowels, but 
also aids the liver in one of its most important duties. As the skin 
is an important eliminating organ, it must be kept clean by frequent 
washing, and if inactive it must be stimulated to increased activity by 
rubbing, and in some cases by hot packs or Turkish baths. (See 
Heat.) 

3. It is of importance, as already stated, that symptoms which 
accompany the progress of various forms of diseases should be modi- 
fied or removed if they become sufficiently active to produce much 
discomfort or disturb the patient's rest. Headache, backache, itchiug, 
wind colic, etc., can often be entirely removed by simple means and 
sometimes without the internal use of drugs. It is, on the one hand, 
important to avoid unnecessary discomfort ; and, on the other, care 
must be taken that in the use of remedies to relieve annoying symptoms 
we do not mask important diagnostic factors in the case or influence 
unfavorably the course of the malady. Thus in appendicitis it is 
wise, as a rule, not to give morphine to relieve the pain, as it will 
quiet the patient so as to lead him and his attendauts to regard the 
condition as actually healed, when in reality the pathological process 
is rapidly progressing. Only when the pain is agonizing ought suffi- 



20 GENERAL THERAPEUTICAL CONSIDERATIONS. 

cient of the drug be given to allay the excess of pain, and never 
enough to mask the real condition. It is of vital importance that the 
physician be not content with the relief of symptoms alone, but that 
he should regard them as of little importance, while he searches for 
and, having found, tries to remedy the diseased state itself. Thus, it 
would be folly to treat the headache of uraemia and fail to treat the 
cause producing it. 

Not infrequently care is not taken to discover whether the patient 
has sufficient sleep or rest. It is perfectly true that if a sick man lies 
awake an hour he is apt to believe he has been awake all night ; but, 
on the other hand, in severe illness prolonged actual wakefulness is a 
very exhausting feature of the attack. Every one of experience has 
seen cases rally when apparently in a most serious state, and conval- 
esce when a good sleep has been given them by the aid of judiciously 
used drugs. If the patient is getting about the normal amount of 
sleep in the twenty-four hours, hypnotics should be avoided as if 
they were poisons. 

THE MODES OF ACTION OF DRUGS. 

To understand the mode of action of remedial measures it is 
essential to recall the facts upon which our practice of therapeutics 
is based. From the earliest times in the history of mankind an 
endeavor has been made to alleviate and cure disease, and for thou- 
sands of years the only reason for applying a remedy in a given 
case rested upon the belief, not necessarily the fact, that it had done 
good in an earlier case which presented a similar chain of symptoms 
or signs. It is manifest that this plan is open to many errors. 
First, the fact that the patient got better after a given plan of treat- 
ment is not a proof in itself that the remedy did the good work. 
It is possible that the patient would have gotten well if left alone. 
Second, the physician and the patient in studying the symptoms may 
very readily misinterpret them, the more so as one patient may place 
great emphasis on one series of symptoms and another patient 
magnify other symptoms which to him may seem of great import- 
ance, whereas they are, in reality, of little value. Third, as no two 
human beings react in an identical manner to the influence of dis- 
ease or remedies, what may be advantageous to one may not be to 
another. Fourth, a remedy which may be of the greatest value at 
one stage of a malady may be useless or even harmful at another. 
All these factors, therefore, stand in the way of obtaining accuracy 
by treatment based on the principle that because U A" has been 
bettered, " B " will be benefited by the same plan. It is not to be 
forgotten, however, that some of these elements of uncertainty can 
be, and are, eliminated if the physician has experience which enables 
him to properly weigh the conditions which he sees or feels, and if 
his experience enables him to attach proper weight to the statements 



GENERAL THERAPEUTICAL CONSIDERATIONS. 21 

of the patient or his friends as to the conditions present. Again, 
if a plan of treatment does good in a large series of cases identical 
in character, it is a justifiable assumption that its effects are real. 
A very large and invaluable part of our methods of treatment at 
present must rest upon the results of clinical observation for obvi- 
ous reasons, and for the additional reasons that until the biologist, 
physiologist, pathologist, and bacteriologist can tell us as to what 
life is, what disease is, and how both life and disease occur, we 
cannot explain how a plan of treatment, proved beyond all doubt 
efficacious, acts. Therapeutics must rest, now and for all time, to 
some extent upon what bedside experience has taught, and this 
experience is so large that it is of inestimable value. 

At times in the past because of lack of knowledge of the functions 
of the body and the cause and course of disease, erroneous ideas 
have developed, particularly when a large series of successful cases 
led to the belief that a plan of treatment did good, when, in reality, 
it was valueless. With the discovery that the plan was an error, 
particularly if the treatment was disagreeable or vigorous, a revulsion 
of feeling occurred, and medical men leaped to the conclusion that 
because this plan was wrong all plans of treatment were wrong and, 
therefore, Avorthless, with the result that they became therapeutic 
agnostics or therapeutic nihilists, than w 7 hich there is no more miser- 
able object in the presence of disease. At a time when excessive 
mistaken medication had reached such a point, through the desire 
of the physician to do good and the demand of the patient that 
something be done, that actual harm often resulted, these therapeutic 
nihilists became divided into two factions : one that said "we can do 
nothing," and the other, w r ith more knowledge of human nature, who 
really did nothing, but pretended that they did something because they 
found that mankind insisted upon at least thinking that efforts were 
being made in its behalf. Led by a clever itinerant theorist, named 
Hahnemann, they developed the idea of infinitestimal doses, and as 
these doses were too small to produce any influence, the patient had 
a chance to get well without having to fight the disease and mistaken 
efforts in his behalf. Hahnemann's plan of treatment was based, 
however, on just as little knowledge of disease and of how drugs 
acted as that of his predecessors, and was more erroneous because, 
in addition to his ignorance, he developed a lot of mistaken ideas 
which he evolved out of his inner consciousness, as, for example, that 
by diluting, grinding, or shaking a drug one could actually increase 
its power over the functions of the body. 

The next step came with the advance of chemistry that gave us 
new drugs and active principles of old ones, so that their complex 
effects could be better separated, understood, and employed, and 
simultaneously physiology and pathology began to discover facts 
which made our conceptions of the functions of the body more 
clear and, therefore, improved our idea as to what happened in disease. 



22 GENERAL THERAPEUTICAL CONSIDERATIONS. 

Before this the morbid anatomist had shown us what the conditions 
were after death, but this gave only a sidelight upon the processes 
during life. In general terms, the conception of the living body as 
an aggregation of living cells may be considered to have been the 
first step toward the more rational therapeutics of to-day. This 
conception of the cells of the body has resulted in many therapeutic 
advances which will be shortly referred to. 

The recognition of the fact that the body is an aggregation of 
living cells was shortly followed by the knowledge that, through 
differentiation and special development, each cell has its own par- 
ticular function to perform, and when this function is perverted or 
arrested illness or death ensues. It also became evident that as 
cells became highly differentiated as to function and form, they 
became susceptible to influences which failed to affect other special 
cells, and knowledge of this fact gave impetus to the next step 
toward modern therapeutics, namely, this explained why certain 
remedies acted upon one part of the body and not on others. , 

The physical, chemical, and physiological state of the cells of the 
body may exercise a bearing on the effect of medicinal or poisonous 
substances. If this is true, we find that the cells of the body may 
possess properties which render them immune to the effects of such 
compounds, whether these compounds remain intact or are broken up. 
Thus, immunity or insusceptibility may be due to the fact that the 
composition of the cell may be so stable that the drug cannot destroy 
it. Its envelope may resist penetration of the drug or, even if it is 
unable to resist penetration, its protoplasm may be of such a nature 
that the drug is not soluble in it. As an example of permeability we 
find that the renal cells are permeable to the sulphates; whereas, the 
cells of the intestinal mucous membrane are impermeable to these 
compounds. Thus, magnesium sulphate taken by the mouth in a 
strong solution remains in the bowel and acts only as a purge. If 
injected in full amount into the blood it is a powerful poison. 

The relationship of ions to the effect of inorganic drugs on the 
body has not been fully determined. When an electrolyte goes 
into solution some of its ions are set free, and, being charged 
with positive or negative electricity, on coming in contact with, or 
entering, the cells thereby produce certain effects or changes — as, 
for example, stimulation or depression — by altering their electrical 
state. 

Again, certain cells of the body, although they may be suscepti- 
ble to a given substance if kept continuously in contact with it, 
nevertheless escape, because it is no sooner taken up than it is 
cast out. 

Many cells otherwise susceptible escape because they have the 
power of oxidizing the substance or of otherwise destroying it be- 
fore it can do harm. This is the explanation of the fact that alco- 
holics and those who have the morphine habit are able to tolerate 



GENERAL THERAPEUTICAL CONSIDERATIONS. 23 

doses which would kill an ordinary man. In other words, their 
cells have had their oxidizing powers greatly increased by training. 
Again, in some manner which we do not understand, cells of the 
body possess the power of becoming accustomed to the presence 
of a given substance, provided its amount at first is not so great 
that the cell is destroyed at once. How this is accomplished we do 
not know. In some instances, particularly if a chemical compound 
be organic and of the nature of a protein poison, the cells protect 
themselves by producing antitoxin. (See Antitoxin.) So far as we 
know, antitoxins are not formed to combine with ordinary chemical 
compounds. 

Conversely, the chemical constitution or function of a cell may 
render it especially susceptible to a given agent, in that its component 
part or parts has an affinity for one or all of the molecules forming 
the compound, as in the case of ether and chloroform, which combine 
with the lipoid or fatty portion of the cells of the higher nervous 
system and cause anesthesia. 

In other instances, a cell suffers not because the agent pri- 
marily is deleterious, but because the cell stores it until its quan- 
tity renders it poisonous in effect. So, too, cells may be affected 
because the compound hydrates or dehydrates, solidifies or lique- 
fies them, or they are influenced by the drug because it dissolves out 
some essential constituent, as, for example, cholesterin or lecithin. 
The process of hydration or dehydration is usually due to the fact that 
a given substance possesses hygroscopic properties, as glycerin, for 
example, or it results in obedience to the law of osmosis. Thus, 
if the proportion of salts in a fluid surrounding a cell is identical 
with the proportion of the salts in a cell, no change occurs; that is, 
the fluid and the cell contents are isotonic. If the proportion of 
salts in the fluid is less than that of the cell (hypotonic), it abstracts 
salt from the cell until the content of cell and fluid is identical ; 
whereas, if the salt content of the fluid is in excess (hypertonic), the 
fluid passes out of the cell until the proportions in cell and fluid 
are equal or isotonic. Certain substances which in themselves are 
practically of little power may, therefore, act as very powerful 
agents because of their dilution or concentration. Thus, sulphate 
of magnesium, given in strong solution to a patient with dropsy, 
causes profuse watery dejections because, being highly concentrated, 
it causes the dehydration of the water-logged tissues, the fluid in 
which pours into the bowel to make the magnesium solution as 
dilute as the juices of the body. If, however, the magnesium 
solution is not concentrated and the patient is lacking fluid because 
of prolonged thirst, the magnesium salt may be absorbed into the 
blood and produce poisonous effects. 

Again, certain cells have so-called receptors, or handles, by 
which they become attached to the drug, which thereby influences 
them. This is particularly true in the case of complex protein 



24 GENERAL THERAPEUTICAL CONSIDERATIONS. 

poisons, as the toxin of diphtheria or tetanus, for example, and 
it is also a fact in the case of many chemical compounds made 
synthetically. (See below.) Indeed, according to some investi- 
gators, the action of morphine in causing sleep is due to the fact 
that the cells of the brain possess receptors for it just as the cells of 
the anterior cornua of the spinal cord possess receptors which unite 
with strychnine. It is doubtful if this is true, however, as to ordi- 
nary alkaloids. 

The structure of the cell, anatomical or chemical, renders it 
susceptible to certain substances. This is illustrated by the fact 
that methylene-blue stains axis-cylinders and sensory nerve-end- 
ings, whereas it fails to stain motor nerve-endings. Furthermore, 
certain cells are not stained by a given dye in health, but are stained 
when diseased, and it is well known in practical therapeutics tnat 
there is a great variation in the effects of remedies upon cells in health 
and disease. 

The result of all these influences is that cells may be altered 
in function ; that is, stimulated, depressed, or perverted. They may 
also suffer organic changes which result in temporary arrest of 
function or in death. 

Last of all, it must be recalled that the susceptibility of cells 
depends, in many instances, solely upon their vitality, for many 
substances which affect living cells fail to affect or enter dead 
cells, and vice versa. This is probably due to some change in 
the anatomical or chemical construction of the cell, and in some in- 
stances it is probably due to the presence of oxygen in or about the 
living cell. Thus, paraphenylenediamine when injected into the blood 
deeply stains brown the central tendon of the diaphragm, the muscles 
of the eye, larynx, and tongue. This is because the cells in these 
areas are so highly endowed with bloodvessels that they contain an 
excess of oxygen, and not because the cells have any special predilec- 
tion for the dye. Ehrlich believes that susceptibility is also influenced 
by the chemical environment of the cell, not only as to oxygen, but as 
to the alkaline and acid reaction. 

It is seen, therefore, that the cell doctrine gave us our first 
clear conception of vital function, and that it, with the study of 
the functions of special aggregations of cells, or cell physiology, 
has led us to the understanding of the physiological effect of many 
remedies. 

It is evident that a medicinal substance may exert an influence on 
the body in many different ways. First, it may act in its original 
form upon those cells of the body which have a special affinity for 
it, or, on the other hand, it may be inactive until it is split up in 
the body into two or more of its component parts, one or all of 
which act on one variety of cells or on different varieties of cells. 
This is illustrated when we administer potassium bromide, potassium 
iodide, or potassium cyanide, for in the body the bromine, iodine, or 



GENERAL THERAPEUTICAL COX SI DERATIONS. 25 

cyanogen is set free and acts powerfully; whereas the potassium 
base produces little or no effect. Much depends upon the readiness 
with which this breaking up occurs. Some compounds soon split 
up in toto, whereas others give up but little of their active com- 
ponent. Thus,, in the case of iodoform the proportion of iodine 
readily liberated is 96.6 per cent. ; that of iodol, 50 per cent. ; that 
of europhen, only 28.5 per cent. 

Again, the various component parts of a drug may be dissociated, 
and then form a new compound or compounds which produce a 
phvsiological effect not possessed by the substance as originally 
given. In the case of hexamethylenamin, commonly called urotro- 
pin, the therapeutic effect of the drug is not exercised as urotropin, 
but as formaldehyde, which is excreted in many secretions, acting 
as an antiseptic. In other instances, such dissociation having taken 
place, one or more of the component parts unites with some sub- 
stance which exists in the body and forms a new and active com- 
pound. 

Furthermore, the readiness with which a drug is dissolved or 
broken up in the organism greatly affects the quickness and sever- 
ity of its influence. As illustrative of this fact we find that phena- 
cetin and acetanilid do not act as such, but only after they have 
become changed into paramidophenol by oxidation, and as phenacetin 
undergoes this change more slowly than acetanilid, it is less powerful 
as a drug and less active when given in poisonous dose. 

Perhaps no better illustration of the activity of a drug, de- 
pending upon the readiness with which it is dissolved and broken 
up in the body, can be cited than the members of the nitrite group, 
in which amyl nitrite acts instantly, nitroglycerin acts a little more 
slowly, nitrite of sodium and nitrite of potassium still more slowly, 
and erythrol tetranitrate more slowly than all the others. In each 
instance the action is identical in kind, but different in degree, because 
of the chemical stability of each compound. Conversely, it is to 
be recalled that many substances which possess a chemical formula 
indicative at first sight of great physiological power are nevertheless 
inert because they are so stable that they are not broken up in the 
body, as, for example, ferrocyanide of potassium, in which neither 
the iron nor hydrocyanic acid exercise any effect because, although 
the latter is by itself a deadly poison, the chemical compound is 
indissoluble in the body. 

At one time it was thought that there might be a definite rela- 
tionship between chemical constitution and physiological action, but 
this has proved incorrect, so far as universal application is concerned. 
It is, however, possible by changing the chemical formula of a sub- 
stance to greatly alter its physiological influence, not only in degree, 
but in kind, and to such an extent that it will no longer affect one 
part of the body, but will influence parts which, in its original form, 
it did not touch. 



26 GENERAL THERAPEUTICAL CONSIDERATIONS. 

There is not space to discuss this in detail, but the following illus- 
trations will suffice. Caffeine, which is trimethylxanthine, increases 
the functional activity of the heart, the respiratory centre, the brain, 
and the muscles, and possesses a moderate stimulant effect on the 
kidneys ; whereas, theobromin, which is dimethylxanthine, that is, 
contains one less methyl molecule, has little effect upon any part 
of the body except the kidneys, which it powerfully stimulates. 
So, too, propyl alcohol (C 3 H 7 OH) is more narcotic than ethyl alco- 
hol (C 2 H 5 OH), and ethyl alcohol is more narcotic than methyl alcohol 
(CH3OH), the addition of one molecule of carbon and two of hydro- 
gen in each instance increasing the power of the compound. In 
the celebrated research of Baumann and Kast they found that sul- 
phones not decomposed in the body are inactive, and that those 
which are decomposed when combined with one or more methyl 
groups are likewise inactive ; whereas, if one or more ethyl groups 
are substituted they become powerful hypnotics, as sulphonal, trional, 
and tetronal. 

Progress along another line resulted from a recognition of the 
fact that many of the disorders of function in the body, and actual 
disease, came about because of the presence, within or without, of 
hitherto undreamed of particles of protoplasm or cells, now called 
microorganisms, or bacteria, or parasites, which directly, or by pro- 
ducing poisons during their life or after their death, destroyed the 
cells of the body of man as completely as more manifest destructive 
agents. With this discovery it became clear that the function of 
the physician was to aid the patient in combating or withstanding 
their attacks, and also to destroy these malign agents if possible. 
In other words, it was learned that the aggregation of cells called 
the living body was aligned in disease against an aggregation of 
other cells, or invaders, or parasites, that sought to live by preying 
upon that body. 

Having made these discoveries and having observed that many 
men and animals recovered when attacked by bacteria or other para- 
sites, it became evident that the aggregation of cells called the body 
must be, in many instances, capable of protecting themselves against 
its enemies, and it became the duty of the investigator to discover 
what these protective methods are. It was soon found that the juices 
of the body and particularly the secretions or products of certain 
tissues, as, for example, the blood-serum and lymph, destroyed and 
dissolved invading germs or parasites (bacteriolysis) ; that certain 
cells of the body, notably certain of the white blood-cells, sur- 
rounded, or swallowed, certain germs and devoured them (phago- 
cytosis) (see Vaccine Therapy), and that a barrier of lymph and 
cells, w T hich rapidly became organized into tissue, walled off the 
seat of invasion from the rest of the body. Further, that the 
lymph-nodes are designed to provide forts or outworks in which 
hosts of devouring white cells battle with invading parasites that 



GENERAL THERAPEUTICAL CONSIDERATIONS. 27 

get so far. It was found that the cells of the body produce some 
substance or substances, as yet not isolated, which render invading 
parasites unable to cope with the phagocytes or white cells (opso- 
nins). These facts having been determined, it was soon discovered 
how the physician can stimulate these protective processes to increased 
activity, as is shown in the text of this book later on. (See Vaccine 
Therapy.) 

It was also noted that certain animals were immune to the action 
of certain microorganisms or their poisons which destroyed man, 
and, therefore, it became evident that such animals must be an 
unfavorable site for their growth ; that is, possessed of the power 
of destroying the invading germs or parasites, or of antidoting 
the poisons they produced after they gained access to the body. 
The idea then followed that by injecting the blood-serum of an 
immune animal into a living body not immune, some of the 
immunity of the animal could be conferred on the man, and this 
proving true the first step in antitoxin treatment of disease was 
taken. 

The sum of all this advance is that at present we can aid the 
body in its endeavor to live by increasing bacteriolysis, by render- 
ing the germs easy of slaughter by the white cells (Vaccine Therapy), 
and by stimulating the cells of an immune animal to increased 
activity we produce an antidote to bacterial or other toxins. (See 
Antitoxins.) 

So far we have considered only the measures by which the body 
can be aided so that it will directly or indirectly combat the attack of 
parasites or their effects. It still remains to discover what can be done' 
to destroy such parasites by giving remedies which will, because of the 
peculiarities of the protoplasm of these invaders, be able to destroy 
them without destroying the cells of the host. Until recently it was 
found that any substance capable of destroying the life of the proto- 
plasm of the invader destroyed the more highly specialized and vital- 
ized protoplasm of the man or animal. 

It is manifest that if certain drugs have a special affinity for certain 
cells in the body, it is probable that there are discoverable substances 
which will have a special affinity for invading cells, and, by attacking 
them exclusively, destroy them alone. To the task of obtaining these 
substances Ehrlich and his co-workers have set themselves, with bril- 
liant results. Ehrlich started out with the hypothesis that for any 
substance to act upon a cell it must become intimately connected with 
it or fixed in it, and that this fixing, or marriage of the cell and the 
substance, can only take place by virtue of the fact that the cell has a 
receptor, or hand, by which it may be attacked or grasped. The re- 
ceptor which takes the chemical substance is called a chemoceptor. It 
follows, therefore, that only those cells which have a receptor fitted to 
grasp a given chemical agent can be effected by it. On this basis he 
sought to find drugs which would unite with the protoplasm of an 



28 GENERAL THERAPEUTICAL CONSIDERATIONS. 

invading parasite, but be unable to damage the body cells, since 
they would have no receptors by which the poison could attach itself 
to them; that is, substances that would be parasitotropic and not 
organotropic. Further than this, he believed, and he proved, that not 
only a single substance could be so used, but that if he formed several 
groups of chemical substances into one fairly firmly connected com- 
pound, the cell of an invading parasite, by having a receptor for only 
one group, would nevertheless fall a victim to all the members of the 
group, although all the other members of the group might have been 
unable to unite with the cell if by themselves. It is as if several 
thieves who could not gain the confidence of a householder, finally 
joined together with another thief, who could worm his way into the 
householder's confidence, and having done so, permit the others to 
prey upon him ; or, to use Ehrlich's own terms, the compound may 
be likened to an arrow, the tip of which enters the body and the 
shaft of which connects the farther end laden with poison to the 
wound. Thus, in the case of salvarsan, described below, which is 
dioxydiamidoarsenobenzol, the excess of the orthoamidophenol fixes 
the drug to the parasite, and so the trivalent arsenic group is enabled 
to reach the arseno-receptor of the cell of the spirochseta. But the 
beneficial effect does not stop here, for the destruction of the parasites 
results in the formation of antibodies, which also destroy any spiro- 
chetal which may have escaped. 

There is not space to describe in detail Ehrlich's work, but, begin- 
ning with the parasite known as the trypanosome, Ehrlich tried the 
effect of various compounds, and found that those of the benzidine series 
destroyed it, particularly one which is red in hue and which he called, in 
consequence, " Trypan Red." Unfortunately this dye, although it de- 
stroyed the trypanosome, also destroyed the host of the parasite. He also 
found that atoxyl destroyed this parasite, and while less toxic to the 
host than Trypan Red, still was deleterious because the cells of the optic 
and acoustic centres contained chemoceptors for this compound. His 
next endeavor was to produce a compound which would combine with 
the receptor of the trypanosome, but with none of the cells of the host, 
and after a time produced arsacetin, which was nevertheless capable 
of being united with some of the cells of the host. After making 
418 compounds, he obtained arsenophenylglycin, which was still less 
hurtful to the infected animal, but yet toxic to a small degree. This 
compound not only killed trypanosomes, but spirilla, as those of relaps- 
ing fever and chicken spirillosis. Next, he produced, as his six hun- 
dredth and sixth product, " 606," which not only acts on the para- 
sites named as well or better than its predecessors, but destroys the 
Spirochseta pallida or parasite of syphilis. This compound, dioxydi- 
amidoarsenobenzol, has little toxic power over the body, but is not 
entirely innocuous, and since then Ehrlich has improved it in this 
respect, producing neosalvarsan "914" (see Part II), a compound 
which is not quite harmless to man, but possessed of an extraordinary 
affinity for the parasite of syphilis; so great an affinity that one large 



MODES OF ADMINISTERING DRUGS. 29 

dose may be capable of destroying every spirochseta in the body of 
an animal. Unfortunately one dose is rarely sufficient in man. 
Ehrlich states that if iodine is introduced into salvarsan it increases 
its effect on spirochaeta of syphilis and diminishes its effect on try- 
panosomes, so that by varying the chemical constitution of a com- 
pound it may be made more specific. Ehrlich's work has, therefore, 
given us a specific remedy for syphilis, yaws, relapsing fever, African 
sleeping-sickness, and holds promise of much more. It could not 
have been accomplished without the knowledge of the cells of the 
body, the advances of bacteriology and chemistry, or without his 
extraordinary ability and training. 

These facts show that therapeutics, with many other branches of 
medical learning, has emerged from pure empiricism into scientific 
accuracy, and stimulate us to aid in the advance and in the practice 
of accurate methods of treatment. 



DIRECT AND INDIRECT ACTION OF DRUGS. 

Drugs act in two ways, which are sometimes called near and 
remote, direct and indirect. The near, or direct, action of a drug is 
that influence which is felt by the exercise of its effect directly upon 
the tissues with which it comes in contact ; the indirect, or remote, 
influence is that result which comes as a sequence of its primary 
effect. As an illustration of this we may take the local use of can- 
tharides. The local, near, or direct effect of this is a blister; the 
remote or indirect effect is the absorption of exudates or the influ- 
encing of inflammatory processes. If pilocarpine is used, its direct 
effect is the sweating which ensues, while its indirect effect is the 
relief of dropsy through the removal of exudate by the increased 
action of the skin, salivary glands, and the kidneys. 



MODES OF ADMINISTERING DRUGS, 

Drugs may be administered for the purpose of affecting the general 
system in many ways, but practically we employ only eight methods, 
as follows : 

1. By the mouth or stomach. 

2. By hypodermic injection. 

3. By intravenous injection. 

4. By intramuscular injection. 

5. By inhalation. 

6. By the rectum. 

7. By inunction. 

8. By fumigation. 

9. By the endermic method. 
10. By cataphoresis. 



30 GENERAL THERAPEUTICAL CONSIDERATIONS. 

By the Mouth — By far the most usual manner of administering 
drugs is by way of the mouth, which is the natural means of en- 
trance into the body for foreign substances. Whenever medicines 
are used in this way the physician should clearly bear in mind 
what the medicine is to do after it is swallowed. If the drug is 
intended to act directly npon the stomach, it should not be given 
after meals, but some time before, since the food and gastric juice may 
afterward so cover the gastric mucous membrane that the medicament 
cannot act upon it. Thus, in a case of chronic gastric catarrh or 
gastric ulcer, the nitrate of silver which is used should always be 
given half an hour or an hour before meals. On the other hand, 
if an ulcer or other trouble exists in the small intestine, the pill 
should be given some time after meals, and if a heavy meal is taken, 
three or four hours after, since under these circumstances the medicine 
is swept out into the intestine almost at once, without remaining any 
time in the stomach, where it may be chemically altered. Very often 
it is necessary to give a medicine soon after food is taken in order that 
it may not act in too powerful or concentrated a manner upon the 
viscus which receives it or upon the general system by reason of its 
rapid absorption in concentrated form. 

The general rule, however, may be laid down that all medicines 
are to be taken after rather than before meals, unless a local gastric 
effect or very rapid absorption is desired. 

It is w r orthy of note that soluble tablets or drops placed under the 
tongue are absorbed almost as rapidly as if given hypodermically. 
This is called "sublingual medication." 

By Hypodermic Injection. — Next to the use of drugs by the mouth, 
by far the most popular method is their administration by means of 
the hypodermic needle and syringe. The logic of this method rests 
upon the absorption of all soluble substances from the subcutaneous 
tissues with great rapidity. Any substance soluble enough or sus- 
pendable enough to pass through a hypodermic needle without form- 
ing an obstruction may be employed, provided it is not too irritating 
and that it is "clean." 

The proper places to give such injections are the forearm, on the 
extensor surface, 1 the abdominal wall, over or into the pectoral muscles, 
or the broad of the back — in other words, any spot where the tissues 
are not dense and unyielding. The skin of the part is to be grasped 
or pinched up with the thumb and forefinger of the left hand and the 
needle sent well into this raised fold, preferably above the finger and 
thumb, so that the pressure of the fingers may prevent pain and hold 
the part steady. The needle should always penetrate well into the 
loose connective tissue, so that the liquid injection may find lodgment 
in the relaxed and spongy subcutaneous tissues without separating the 
skin from its rather close adhesions to the tissues below or from the 

1 Hypodermic injection into the anterior aspect of the forearm often causes much 
pain in the hand by irritating temporarily the branches of the radial or ulnar nerves, 



MODES OF ADMINISTERING DRUGS. 



31 



bloodvessels supplying it, for if separation occurs abscess and a slough 
may result. 

The dangers from hypodermic injections are chiefly two. First: 
The needle may enter a vein, and the entire dose be carried at once, 
en masse, to the vital centres. Second : The solution or needle used 
may not be sterile, and an abscess result. The first danger is to be 
avoided by injecting into parts not well supplied with veins, and the 
second by thoroughly washing both syringe and needle with sterile 
water the instant before they are used, pushing a fine wire through 



Fig. 1. 




Method of giving a hypodermic injection. The skin having been sterilized, the 
needle is then pushed into the subcutaneous tissues, as shown in the illustration. If 
the injection is given into the forearm, the skin of the part into which the injection 
is to be given is to be raised by grasping it between the thumb and fingers of the left 
hand to aid in holding the forearm steady. 

the needle, and in some cases by soaking the instrument in carbolized 
oil. The solution injected should be prepared by using freshly boiled 
water and adding thereto phenol in such proportion that one-half 
drop is ^ present in each injection if a solution is to be permanent. 
It is claimed by some that this use of phenol seriously hinders ab- 
sorption, and in cases of urgency it should not be used. Most 
physicians now make a solution for immediate use by adding a small 
tablet of the required drag to 20 minims of water at the moment it 
is needed. A third danger supposed to exist by some persons, but 
probably more feared than need be, is the injection of air into a vein 
with the medicament. It is well to see that all air is expelled from 
the syringe before making the injection. Most hypodermic syringes 
hold from twenty to thirty minims. 



32 GENERAL THERAPEUTICAL CONSIDERATIONS. 

By Intramuscular Injection. — Meltzer and Auer have shown that the 
rapidity of the absorption of a drug when given by the hypodermic 
needle is greatly increased if it be injected into the belly of one of the 
larger muscles. This rapidity of action almost equals that of an intra- 
venous injection. 

By the Rectum. — When drugs are given by the rectum, we employ 
them for three purposes : first, to influence the general system by their 
absorption; secondly, to act locally upon any disease which may be 
present in this particular locality or in the colon; and, finally, to dis- 
lodge substances or parasites which it is desired to bring away. The 
word " enema " is loosely used to denote all these injections, be their 
purpose what they may, and is synonymous with "rectal injection " 
or the more old-fashioned word "clyster." If nourishment is being 
given, the injection is called a " nutrient enema." Sometimes these 
injections are called " lavements." The efficiency of medication by 
the rectum depends greatly upon the character of the substance in- 
jected. When food-stuffs are given in this way, in all probability 
little more than their salts and fluids are absorbed. When very 
soluble alkaloids, such as strychnine sulphate is used, the absorption is 
very rapid and complete. 

In this mode of administration it is very necessary that the physi- 
cian should use the medicaments in proper bulk ; and it may be laid 
down as a rule that no more liquid should be injected than is neces- 
sary to convey the medicine or food unless the injection is for the 
purpose of emptying the bow T el of fecal matter or other materials, or 
it be desired to distend the bowel in order to overcome obstruction, 
or to influence the colon by drugs. 

The reason for this lies in the fact that any large bulk of liquid 
sent into the rectum so stimulates the walls by distention as to cause 
spasmodic contraction, with expulsion of all the rectal contents, which 
is just what is needed when fecal matter is to be removed, but the 
opposite of what is desired when retention of a remedy or food is 
necessary for absorption or local action. In rectal catarrh or ulcers 
two to four ounces of liquid are usually sufficient in an adult to accom- 
plish any medicinal influence locally or by absorption, while as a laxa- 
tive enema one to two pints may be employed. 

In the use of injections the rectum frequently becomes irritable, 
and resists all efforts to force the entrance of liquids or solids. This is 
to be avoided by giving the injection so gently that the bowel fails to 
recognize, as it were, the entrance of the liquid, and by introducing a 
few drops of oil and laudanum in each injection. 

A large amount of distress often follows the gradual accumulation 
of fecal masses in the colon which are not passed with the daily move- 
ment of the lower bowel. These can readily be removed by large 
injections of warm water or by the use of medicated liquids. 

When a large quantity of w r ater is used, it should be warmed to 
100° F. or a little more, and it is well to add salt to it, so that it 



MODES OF ADMINISTERING DRUGS. - 33 

will represent the normal saline strength of blood-serum, namely, 
0.7 per cent. (For use of injections in special diseases, see Part IV., 
and for Enteroclysis, Part III.) 

Suppositories are another means by which medicines are introduced 
into the bowel, either for local effect or to act, after absorption of 
their contents, upon the general system. 

By Inhalation. — When drugs are given by inhalation they are gen- 
erally employed with the object of affecting the respiratory tract alone ; 
notable exceptions are ether, chloroform, nitrous oxide gas, and other 
volatile substances. Aside from anaesthetics are such remedial meas- 
ures as the inhaling of steam laden with the drugs employed, the 
respiring of air charged with the fumes of the medicament, or the 
inhalation of gases, and last, and most commonly resorted to of all, 
the use of the vaporizer, which, if properly made and employed, so 
minutely divides the liquid containing the medicament that the inspired 
air carries it to the farthest bronchiole and pulmonary vesicle. (See 
Part III.) Atomized sprays have also been found to possess great 
penetrating power in the treatment of inflammation under the skin or 
mucous membranes, as, for example, boils or carbuncles. 

As an example of the rules governing the administration of drugs in 
this manner we find that compound tincture of benzoin may be taken 
by inhaling the steam arising from hot water containing it, but cannot 
be used in a spray because it occludes the fine points of the atomizing 
tubes. In a similar manner the smoke of belladonna or tobacco-leaves 
may be inhaled to relieve asthma, or the fumes of chloride of ammo- 
nium for bronchitis in its later stages. Fumigation with mercury, 
the sublimed vapor being inhaled, is also useful in syphilis. Finally, 
we find that oxygen is sometimes very useful, the gas being readily 
inhaled, with good results in proper cases. 

The " spray " or atomizer is made in two forms — one form of appa- 
ratus being operated through the agency of compressed air, the other 
through the escape of steam from a small boiler. Very few of the 
compressed-air atomizers throw a spray sufficiently fine to reach the 
deeper parts of the lungs, particularly if the air is compressed by the 
hand ; but all instrument-makers now sell vaporizers or nebulizers 
which so minutely divide the liquid medicament that it readily enters 
the deeper parts of the lungs. 

The inhalation of moist air is very useful in bronchitis, and greatly 
aids other remedial measures. Steam may be disengaged in a room 
by means of a kettle of boiling water or by placing pieces of unslaked 
lime in a pan of water. 

By Inunction. — Inunctions consist in the rubbing into the skin of 
medicines, generally of an oily or fatty nature, or which assume this 
character through embodiment with oil or fat. Fatty substances are 
absorbed through the skin by way of the sebaceous glands, not 
through the epiderm, and, therefore, substances not fatty are but 
poorly absorbed when applied by inunction. The three substances 
3 



34 GENERAL THERAPEUTICAL CONSIDERATIONS. 

most commonly used in this way are cod-liver oil, mercurial oint- 
ment, and iodine ointment. They should always be applied on some 
part where the derm is thin and well supplied with subcutaneous 
lymphatics, as in the axillae, the groins, or the insides of the thighs. 
Other substances have been and may be used by inunction; but as 
this method is necessarily a disagreeable and dirty one, it is rarely 
resorted to unless the stomach is disordered or it is necessary to cause 
absorption of the drug by every possible avenue of entrance. 

The Endermic Method. — -The endermic method consists in the use of 
a blister, by means of which the epiderm is raised, when a little mor- 
phine or other alkaloid may be slipped under it and so absorbed through 
the true skin. It is a painful method, almost never to be resorted to, 
having been supplanted by the hypodermic method of medication. 

Drugs are also sometimes caused to enter the body through the skin 
by placing them in plasters or poultices, or by the electrical process 
called cataphoresis. (Part III.) 

PHARMACEUTICAL PREPARATIONS. 

Remedies are administered in a number of forms, but chiefly as 
follows : 

Abstracts are dry powdered extracts mixed with sugar of milk 
until they are twice as strong as the crude drug. Abstracts are no 
longer official in the United States Pharmacopoeia. 

Aceta, or vinegars, are solutions of the active principles of 
drugs in vinegar or dilute acetic acid. There is one in the United 
States Pharmacopoeia (Acetum S cilice) and three in the British 
(Acetum Cantharidini, Acetum Urginea, and Acetum Scillce). 

Alkaloids are organic bases, forming salts with acid radicals, gen- 
erally occurring in crystalline form and abstracted from crude drugs. 
They nearly always represent the active principle of the drug. 

AQUiE, or waters, are used as vehicles either for the dilution of 
strong medicines or for the purpose of carrying minute amounts of 
flavoring materials. 

Cataplasms are not official in the United States Pharmacopoeia. 
They are virtually poultices made of linseed-meal or of bread-crumbs. 

Cerates are ointments containing wax to render them harder than 
would ordinary fats. 

Charts, or papers, consist of bibulous paper soaked in a solution 
of the drug which they are intended to carry. 

Confections are sometimes called electuaries or conserves, and 
are soft pastes which contain the drug mixed with sugar or honey. 

Decoctions are solutions of drugs made by boiling and then strain- 
ing while hot. 

Elixirs are sweetened alcoholic liquids rendered pleasant to the 
taste by the addition of aromatic substances and sugar. 

Emplastra, or plasters, are made up of adhesive substances placed 



PHARMACEUTICAL PREPARATIONS. 35 

upon a backing of cloth or leather and designed to adhere to the skin, 
being so applied for the purpose of holding a medicinal substance in 
contact with the body, of acting as a protective, or of aiding in the 
approximation of the edges of a wound. 

Emulsions are liquid preparations which consist of oily substances 
minutely subdivided and held in suspension in water usually by some 
gummy material. 

Extracts consist of the soluble parts of plants reduced to a semi- 
solid or solid condition by evaporation ; the soluble constituents being 
taken from the plant by water or alcohol. 

Fluidextracts are alcoholic solutions made in such a way that 
each mil. equals 1 gram of the crude drug. 

Glycerita, or glycerites, are solutions of various substances in 
glycerin — the glycerin being used as a vehicle. 

Infusions are made by pouring boiling water on the crude drug 
and allowing it to stand for a short time until the water cools, after 
which the liquid is strained. Sometimes cold water is employed. 

Liniments are made of oily substances often mixed with powerful 
drugs to increase their efficiency. 

Liquors are usually watery solutions of non-volatile drugs. 

Mixtures are composed of two or more drugs or of a single drug 
partly dissolved and partly in suspension. 

Pills are small round masses which, as a general rule, should not 
weigh more than three grains, in order to avoid too great bulk. If 
the material is a heavy one, as much as five grains may be placed in 
each pill. Pills may be without covering or coated with sugar or 
gelatin to preserve them and prevent the patient from tasting their 
contents. Sugar-coated pills must always be fresh and the sugar- 
coating pure. Gelatin is the best coating for pills. Many pills are 
fraudulently coated with varnish and are insoluble. 

Spirits are alcoholic solutions of volatile substances. 

Suppositories are small masses made into a cone shape and hav- 
ing for their basis cacao butter. They are designed to carry into the 
rectum certain medicines for absorption into the system or for local 
action. 

Syrups are solutions of sugar in water or in medicated aqueous 
liquids. They are used as vehicles. 

Tablets. — Under this name manufacturing pharmacists and 
others prepare compressed pills or lozenges, generally of small size, 
the mass being made to adhere by means of its being subjected to 
great pressure by special machinery. Smaller tablets are used for 
carrying powerful drugs for hypodermic use. These, however, are 
often only lightly pressed, so as to render them easily soluble. 

Tinctures are solutions of the active principles of drugs in alcohol 
or in mixtures of alcohol and water. 

Triturates are made by adding 10 per cent, of the active medi- 
cine to 90 per cent, of milk-sugar. These are then carefully rubbed 



36 GENERAL THERAPEUTICAL CONSIDERATIONS. 

together until the two are intimately mixed. Triturates are valuable 
in the administration of medicines to adults or to children. These 
triturates are often made into tablets, forming what are known as 
"Tablet Triturates." 

Troches, or lozenges, are flat, hardened, medicated masses designed 
to be held in the mouth, so that they may be slowly dissolved, thereby 
affecting the local mucous membrane. 

Unguenta, or ointments, are unctuous preparations containing 
medicinal substances which melt at the temperature of the body. 

Wines are made in the same way as tinctures — strong white wine 
being used in the United States, and sherry or orange wine in Great 
Britain, in place of ordinary alcohol. 

WEIGHTS AND MEASURES. 

There are two systems of weights and measures employed in the 
United States at the present time. The one most commonly used 
is the old-fashioned system of Apothecary weights for solids, and the 
Wine, or Apothecary, measures for liquids. The newer and more 
accurate system is that known as the Metric, or Decimal system of 
weights and measures, which is now recognized and recommended by 
the Pharmacopoeias of the United States, Great Britain, Germany, 
and France. 

The divisions of Apothecary weights are the pound, the ounce, 
the drachm, the scruple, and the grain. The scruple, which equals 
20 grains, has dropped out of use, chiefly because the scruple mark 
when written somewhat resembles that of the drachm. We may say, 
therefore, that the Apothecary weights consist of a pound, equalling 
12 ounces, or 96 drachms, or 5760 grains ; that the ounce represents 
8 drachms, or 480 grains ; and that the drachm equals 60 grains. 
The abbreviation for the word grain is "gr." ; for the drachm, 5 ; for 
the ounce, 5 ; and the pound, tb. 

In the Wine, or Apothecary, measures we have the gallon, the pint, 
the fluidounce, the fluidrachm, and the minim. In each gallon there 
are 8 pints, 128 fluidounces, 1024 fluidrachms, and 61,440 minims. 
In each pint there are 16 fluidounces, 128 fluidrachms, and 7680 
minims. In each ounce there are 8 fluidrachms and 480 minims. 
In each drachm there are 60 minims. The abbreviation of the Latin 
word " minimum " or " minim " is HI ; of the fluidrachm, f 5 ; of the 
fluidounce, f 5 ; of a pint, or " octarius," O ; and of the gallon, or 
"congius," Cong. 

The British Pharmacopoeia has adopted the Avoirdupois system 
of weights, and thereby has a system which differs somewhat from 
the Apothecary weights of the United States Pharmacopoeia. The 
Avoirdupois pound represents 16 ounces, or 7000 grains ; the Avoir- 
dupois ounce, 437.5 grains. It will be seen, therefore, that the 
Apothecary pound contains 1240 grains less than the Avoirdupois 
pound, but that the Apothecary ounce contains 42J grains more 



WEIGHTS AND MEASURES. 37 

than the Avoirdupois ounce. Fortunately, however, the grain, both 
of the Apothecary and Avoirdupois systems, is of identical value. 
So, too, the British Pharmacopoeia uses what is known as the Im- 
perial system of measures in place of the Wine measures used in the 
United States. Thus, the Imperial gallon represents 8 pints, 160 
fluidounces, 1280 fluidrachms, and 76,800 minims; the Imperial 
pint, 20 fluidounces, 160 fluidrachms, and 9600 minims; and the 
fluidounce, 8 drachms or 480 minims. The fluidrachm equals 60 
minims. It will be seen, therefore, that the Imperial measure differs 
from the wine measure chiefly in having 20 fluidounces in each pint, 
instead of 16. So, too, the weight of the Imperial fluidounce contains 
the same number of grains as the Avoirdupois ounce, which is 18.2 
grains less than the weight of the United States fluidounce, which is 
455.7. These differences between the weights and measures used in 
the United States and Great Britain are, therefore, of little import- 
ance when we are employing grains or minims, but they become of 
great importance when we employ ounces, and of still greater im- 
portance when we employ pounds or pints. In the average prescrip- 
tion, however, which rarely exceeds three or four ounces, the dif- 
ference in quantities in the United States and Great Britain are not 
of very great importance. 

The advantages of the metric system over these irregular systems 
of weights and measures are the same as those of the decimal system 
of currency over the English system of pounds, shillings and pence. 
The unit of all calculations is the metre, which in the metric system 
is the unit of length. From this is derived the unit of capacity, the 
litre, which is the cube of one-tenth of a metre ; and from the litre is 
derived the unit of weight, the gramme, which is the one-thousandth 
part of the weight of a litre of distilled water at its maximum density. 
As a matter of fact, the metric system is no more difficult to master 
than is the system of dollars and cents. The great difficulty is that 
the majority of physicians having learned the doses of various prepara- 
tions in the Apothecary weight find it difficult to begin using the 
metric system, and do not take the trouble to convert the Apothecary 
doses into this system. 

In the metric system we have the gramme (Gm.) which may be 
said to be the equivalent of the dollar ; the decigramme, or one-tenth 
of a gramme, which represents the dime ; the centigramme, or one- 
hundredth of a gramme, which represents the cent ; the milligramme, 
or the one-thousandth of a gramme, which represents the mill. Above 
the gramme in quantity we use what is known as the decagramme, 
which corresponds to the gold eagle, or ten dollars ; the hectogramme, 
which corresponds to one hundred dollars ; and the kilogramme > 
which corresponds to one thousand dollars. When we come to the 
use of the metric system for fluids, we use as the unit the milliliter, 
called the "mil.," or cubic centimetre (Cc.) in place of the gramme; 
a mil. or cubic centimetre representing 1 fluidgramme. 



Gramme 


0.12 is equal to 0.12 


Grammes 


3.9 are " " 3.9 


Gramme 


0.06 is " " 0.06 


Gramme 


0.0006 " " " 0.00C 



38 GENERAL THERAPEUTICAL CONSIDERATIONS. 

When it is wished to convert grains into their metric equivalent, 
it must be remembered that 0.065, or 65 milligrammes, is the equiva- 
lent of 1 grain. Therefore, the following examples may be used: 

3 grains are equal to 3 X 0.065 = 0.195 gramme. 
60 grains are equal to 60 X 0.065 = 3.9 grammes. 1 

J grain is equal to | of 0.065 = 0.0162 gramme. 

y^o grain is equal to y^~o of 0.065 = 0.00065 gramme. 

To convert grammes into grains, instead of multiplying by 0.065, 
we divide, thus : 

-j- 0.065= 1.8 grains. 
~- 0.065=60 grains. 

h- 0.065= 0.9 grain. 
■+- 0.065= 0.0092 grain. 

When we wish to convert apothecaries' drachms into grammes, we 
multiply the number of drachms by 3.9, or more commonly, though 
less accurately, by 4.0. Thus : 

10 drachms X 4.0=40 grammes, or, more accurately, 
10 drachms X 3.9=39 grammes. 

When grammes are to be converted into drachms, we divide the 
number of grammes by 3.9, or approximately 4.0. Thus : 

10 grammes ^-3. 9 = 2. 5 6 drachms, or, less accurately, 
10 grammes-^ 4,0= 2.5 drachms. 

When Apothecary ounces are converted, we multiply by 31.1 ; or 
if grammes are to be converted into ounces, we divide by 31.1. 
Thus : 

2 ounces Xby 31.1 = 62.2 grammes. 
40 grammes-^- by 31.1= 1.25 ounces. 

As accurate translation of apothecaries' weights into the metric 
system leaves a fractional quantity in almost every instance, and as 
the translation of the metric system into apothecaries' weights does 
likewise, the author has for the sake of presenting even figures, and 
therefore rendering the interchange practicable, considered that the 
Apothecary ounce and the fluidounce are equal to 30 grammes or 30 
mils, or cubic centimetres, although a more accurate estimate of the 
ounce is 31.1 and of the fluidounce is 29.57. 

1 Usually considered as 4.0. 



WEIGHTS AXD MEASURES. 



39 



TABLES OF RELATIVE WEIGHTS AND. MEASURES IN THE 
METRIC AND APOTHECARIES' SYSTEMS. 

(See Oldberg's Manual of Weights and Measures.) 







Milligrammes 


in Grain 


s. 






Milligramme 




Grain. 


Milligrammes. 


Grain. 


Milligrammes 


Grain. 


0.1 


= 


^o"o 


1 


= 


l 

60" 


8 


= 


i 


0.2 


= 


"300" 


1.2 


= 


30" 


9 


= 


\ 


0.3 


= 


i 

200 


1.6 


= 


& 


10 


= 


1 


0.4 


= 


T30" 


2 


= 


1 
^O" 


12 


= 


I 


0.5 


= 


1 

TTO" 


3 


= 


& 


16 


= 


i 

4 


0.6 


= 


IM 


4 


= 


1 
T5" 


20 


= 


1 
"3 


0.7 


= 


io 


5 


= 


A 


30 


= 


* 


0.8 


= 


1 

80 


6 


= 


A 


60 


— 


1 


0.9 


= 


1 
TO" 


7 


== 


* 












c 


ENTIGRAMMES 


in Grain 


3. 






Centigrammes 


Grain. 


Centigrammes. 


Grains. 


Centigrammes 




(or Cent.) 




(or Cent.) 






(or Cent. 




Grain 


1 


= 


l 

6 


6 


= 


1 


18 


= 


3 


2 


= 


i 


7 


= 


H 


25 


= 


4 


3 


= 


\ 


9 


= 


i* 


50 


= 


8 


4 


= 


2 


10 


= 


if 


75 


= 


12 


5 


= 


f 


12 


= 


2 


100 


= 


16 








Grammes in 


Grains. 








Grammes. 




Grains. 


Grammes. 




Grains. 


Grammes. 




Grains 


0.001 


= 


l 

60 


11 


= 


176 


27 


= 


432 


0.010 


= 


1 

6 


12 


= 


192 


28 


= 


448 


0.100 


= 


1 2 


13 


= 


208 


29 


= 


464 


0.250 


= 


4 


14 


= 


224 


30 


= 


480 


0.500 


= 


8 


15 


== 


240 


31 


= 


496 


0.750 


= 


12 


16 


== 


256 


32 


= 


512 


1 


= 


16 


17 


= 


272 


33 


== 


528 


1.50 


= 


24 


18 


= 


288 


34 


= 


544 


2 


= 


32 


19 


= 


304 


35 


= 


560 


3 


= 


48 


20 


= 


320 


36 


= 


576 


4 


= 


64 


21 


= 


336 


37 


= 


592 


5 


= 


80 


22 


= 


352 


38 


= 


608 


6 


= 


96 


23 


= 


368 


39 


= 


624 


7 


= 


112 


24 


= 


384 


40 


= 


640 


8 


= 


128 


25 


= 


400 


50 


= 


800 


9 


= 


144 


26 


= 


416 


100 


= 


1600 


10 


= 


160 















40 



GENERAL THERAPEUTICAL CONSIDERATIONS. 



Mils, or Cubic Centimetres (or Fluid grammes) in U. S. Apothecaries' 









Fluidrachms. 












U.S. 






U.S. 






u.s. 


Mils. 




Fluidrachms. 


Mils. 




Fluidrachms. 


Mils. 




Fluidrachms. 


1 


= 


l 

4 


9 


= 


2i 


16 


= 


4 


2 


= 


l 

•2" 


10 


= 


2* 


20 


= 


5 


3 


= 


3 


11 


= 


2f 


24 


= 


6 


4 


= 


1 


12 


= 


3 


28 


= 


7 


5 


= 


li 


13 


= 


3i 


32 


— 


8 


6 


= 


n 


14 


= 


3i 


48 


= 


12 


7 


= 


if 


15 


= 


3f 


64 


= 


16 


8 


=3 


2 















Table of Approximate Percentages. 





Grains per 
Fluidrachm. 


Grains per 


Grains per 


To make — 


Fluidounce. 


Fluidpint. 


1 per cent 


0.60 


5. 


73. 


2 " 










1.15 


9.15 


146. 


3 










1.70 


14. 


219. 


4 










2.30 


18.25 


292. 


5 " 










2.85 


23. 


365. 


6 










3.40 


27.50 


438. 


7 










4. 


32. 


511. 


8 










4.60 


36.50 


584. 


9 










5.15 


41. 


657. 


10 










6. 


46. 


730. 


Based on 57 


mi 


n. 


to 


t 


he drachm, 457 min. 


to the ounce, and 73 


00 min. to the pint. 



DOSAGE. 

No one can practice medicine for more than a very brief period 
without becoming convinced that quite as much skill is required on 
the part of the practitioner in determining the dose which is needed 
of a given remedy as in deciding upon the remedy itself. It 
repeatedly happens that one physician fails to produce the desired 
results, while another physician immediately gets good effects from 
the same remedy, for no other reason than that he has been more 
skilful in determining the amount which should be administered and 
the frequency of its administration. 

In teaching medical students the dose of remedies it is impossible 
to do more than inform them of the approximate doses.^ Only 
experience can tell the individual physician the amount which will 
be needed in a given case, and often even those with the largest 
experience have to try several doses before they find the one which 
produces the effects they desire. These facts have much to do 
with the contradictory ideas which exist in different men's minds 
as to the efficiency of a given remedy. One physician states that he 
frequently employs a certain drug and has come to rely upon it as a 
"sheet-anchor" when conditions are desperate; another physician 
replies that he has tried it, and that his results have been as lacking 
in success as the other's have been full of good. This difference of 






DOSAGE. 



41 



Acetum lobeliae 

Acetum opii 

Acetum sanguinariae . . . . 

Acid, acetic 

Acid, acetic, dilute 

Acid, carbolic 

Acid, hydro-bromic 

Acid, hydrochloric 

Acid, hydrochloric, dil. . . 

Acid, nitric 

Acid, nitric, dilute 

Acid, nitrohydro^hloric. . . 
Acid, nitrohydrochloric. di- 
lute 

Acid, phosphoric 

Acid, sulphuric 

Acid, sulphuric, dilute . . . 
Acid, sulphuric, aromatic. . 

Aqua ammoniae 

Aqua destillata 

Liquor potass, arsen 

Oleum anisi 

Oleum amygdalae amar. . 

Oleum cari 

Oleum chenopodii 

Oleum carophylli .... 

Oleum cinnamomi 

Oleum crotonis 

Oleum cubebse 

Oleum gaultherise 

Oleum hedeomae 

Oleum lavandulae 

Oleum monardae 

Oleum menthae pip 

Oleum menthse viridis . . . 

Oleum myristicae 

Oleum origani 

Oleum pimentae 

Oleum rosmarini 

Oleum sassafras 



Dropped from 






6 






_ u 


GG.Q 


r2 o 




51 


48 


64 


66 


57 


65 


102 


92 


92 


82 


49 


101 


94 


55 


99 


82 


66 


110 


57 


65 


70 


60 


57 


96 


70 


51 


62 


82 


66 


124 


63 


60 


81 


87 


74 


92 


58 


54 


62 


54 


43 


62 


160 


152 


172 


57 


47 


60 


97 


94 


144 


45 


41 


54 


64 




61 


58 


61 


77 


76 


73 


112 


102 


77 


75 


108 


84 


133 


94 


75 


129 


98 


75 


133 


77 


73 


112 


84 


62 


104 


86 


80 


120 


93 


93 


136 


95 


83 


130 


105 


78 


133 


82 


76 


125 


88 


73 


132 


95 


81 


132 


98 


83 


128 


91 


83 


133 


102 


86 


133 


92 


88 


133 


83 


77 


142 



Oleum tanaceti . . . 
Oleum terebinthinae , 
Spiritus ammon. ar. . 
Spiritus camphorae . 
Spiritus aether, comp 
Spiritus aether, nitr. . 
Spiritus menthae pip. 
Syrupus scillae comp. 
Tinctura aconiti . . 
Tinctura asafoetidae . 
Tinctura belladonnae 
Tinctura benzoini co. 
Tinctura cannabis ind 
Tinctura cantharidis 
Tinctura capsici ... 
Tinctura colchici . . 
Tinctura digitalis - . 
Tinctura ferri chlor. 
Tinctura hyoscyami 
Tinctura ignatiae . 
Tinctura iodi . . . 
Tinctura kino . . 
Tinctura krameriae 
Tinctura lavand. co 
Tinctura lobeliae 
Tinctura myrrhae . 
Tinctura nucis vomicae 
Tinctura opii . . 
Tinctura opii cam ph. 
Tinctura opii deodor. 
Tinctura rhei .... 
Tinctura sanguinariae 
Tinctura stramonii . 
Tinctura tolutani . . 
Tinctura veratri . . . 
Vinum aloes . . 
Vinum colchici rad. . 
Vinum colchici sem. 
Vinum ergotae .... 
Vinum opii 



Dropped from 



053 



110 
103 
108 
98 
120 



106 
120 
102 



124 

118 

116 

86 

114 

108 

114 

112 

112 

116 

117 

97 

110 

100 

112 

98 

94 

109 

98 

110 

100 

120 

108 

71 

92 

86 

148 



87 
102 
85 
81 
81 
120 
97 
88 
80 
79 

'91 

83 
97 

100 
96 
86 
79 
95 

105 
92 



^2 

.as 



136 
142 
139 
140 
140 
144 
143 
122 
164 
145 
128 
146 
98 
136 
143 
124 
145 
139 
147 
140 
144 
148 
150 
141 
138 
145 
148 
143 
135 
141 
144 
134 
120 
156 
152 
94 
95 
105 
122 
102 



opinion does not rest upon any lack of power of observation on the 
part of either man, but upon the judgment of each as to the amount 
of the remedy to be used. If there were more accurate statements 
made as to the doses employed when remedies are suggested by one 
practitioner to another, better results would accrue. 

It is also probably the case that certain physicians consistently 
administer remedies in doses which are too large, or which speedily 
become too large because the drug is one which is persistent in its 
effect, so that after a few doses the patient is not only under the 
influence of the remedy administered on that particular day, but 
also under the influence of doses which have been administered on 
previous days. Then there is the physician who habitually uses too 
small doses, and it may be that in a large number of cases he is a 
better practitioner than he who gives the large ones. Sometimes 
rapidly acting, but fugacious, remedies are given at too long inter- 
vals, or doses of slowly acting, persistent remedies are given too close 
together; and, again, sufficient judgment is not exercised in deter- 
mining exactly what is to be accomplished in a given patient at a 



42 GENERAL THERAPEUTICAL CONSIDERATIONS. 

given time. Thus, in the administration of digitalis it is often wise 
to give one or two rather large doses, and almost always unwise to 
continue them, the proper method being to correct urgent symptoms 
by large doses and then maintain the good effect by smaller ones, 
thereby preventing an excessive digitalis effect, which may be more 
disagreeable or harmful to the patient than the condition for which 
the remedy is administered. 

Another illustration of this is in the administration of alkalies for 
the purpose of combating the acidosis which induces or accompanies 
diabetic coma. It is generally known that sodium carbonate and 
sodium bicarbonate are to be given by rectal injection or by intra- 
venous infusion in order to, at least in part, combine with these 
acids, but in many instances the quantity of alkali which is given 
is quite insufficient to produce the results desired, because the 
physician does not estimate the degree of the acidosis. It is not 
at all -uncommon for these acids to amount to as much as 10 to 
20 grammes in the twenty-four hours, and many instances are on 
record in which several times this quantity has appeared in the urine, 
which is an index of the total acidosis of the body. Manifestly 
different doses of alkali have to be used in such cases, and sometimes, 
instead of giving as much as a drachm, or 4 grammes, it is proper to 
give as much as 3 or 4 ounces of sodium bicarbonate in each twenty- 
four hours. Cases are on record in which as much as 900 grammes, 
or 30 ounces, of sodium bicarbonate have been administered without 
neutralizing the urine. In other words, in this condition the alkali 
should be given for effect and not by weight, the principle governing 
its administration being more akin to the employment of an antidote 
in mineral poisoning, or the use of antitoxin in diphtheria, rather 
than to the adjustment of the dose of a drug ordinarily employed for 
the purpose of producing a physiological effect. 

For several reasons there is no absolutely fixed rule which can be 
applied to dosage. In the first place, the individual may not be 
readily affected by drugs, or the disease-process present may so 
antagonize them as to render very large doses necessary. Further, 
the age and sex of a patient have much to do with the regulation of 
the proper amount of a drug to be employed. Finally, that curious 
but common condition of susceptibility to various remedies, that we 
call idiosyncrasy, creeps in as an important factor in the decision as to the 
dose which should be given in each case. By far the nearest aj^proach 
which can be made to absolute accuracy in dosage is to use drugs accord- 
ing to the weight of the patient, but this method possesses the disadvan- 
tage that we cannot always weigh our patients, and that the presence of 
a large amount of fat or of dropsy will make an unknown quantity in 
the calculation as to the true weight of the active part of the individual. 

At present we are accustomed to be governed by a list of doses to 
be given to all adults within certain limitations, and which are varied 
sufficiently to permit of great differences in the effects obtained. It 



DOSAGE. 



43 



is in this very factor that the success of many a physician chiefly rests. 
The dose must be varied to fit the case in the same manner that the 
cut of a coat must be varied to fit each individual. 

As already stated, there is not a uniform dose of all preparations of 
the same class, but it will aid the student to bear the following facts 
in mind: With a few exceptions the dose of solid extracts of nearly 



Fig. 2. 



Fig. 3. 



Fig. 4. 






Graduated medicine glasses. 



all the powerful drugs is about J to J grain (0.008-0.016) ; of fluid- 
extracts of nearly all powerful drugs about 2 to 5 minims (0.12— 
0.3) ; of aromatic oils and liquors containing powerful drugs about 
6 to 10 minims (0.36-0.6) ; of tinctures of powerful drugs about 
5 to 20 minims (0.3-1.3), except cantharides and iodine, the dose 
of which equals about 2 to 6 minims (0.12-0.36). Of official waters 
the dose is about 1 drachm to 1 ounce (4.0-30.0), and of infusions 
and decoctions about 1 drachm to 1 ounce (4.0-30.0). 

There are a number of approximate rules in regard to the doses 
which are to be given in treating the diseases of children, the best of 
which is Young's rule. This is as follows : 

Add 12 to the age and divide by the age. Thus, if a child is two 
years old, we have the following formula : 2 + 12 = 14-^2=7, or, one- 
seventh of the dose for an adult is the dose for a child of two years. 
This rule is not a law, however, for of narcotics children should 
receive less than this (one-half), and of purgatives or laxatives nore 
than this (two or three times). 

When drugs are given hypodermically the dose should be generally 
one-half to one-quarter of that given by the mouth ; and if any sus- 
picion of idiosyncrasy exists, the dose should be smaller still at first if 
powerful remedies are to be used. 

By the rectum the dose should be twice the amount given by the 
mouth, unless the drug be very powerful or capable of very rapid 
absorption. 

When ordering liquid medicines in small amounts the prescription 
should always call for minims rather than drops, for the size of a drop 
varies with the particular liquid with which we are dealing and the 



44 GENERAL THERAPEUTICAL CONSIDERATIONS. 

shape of the mouth of the vessel containing it. This is well shown in 
the table on p. 41, compiled by Kinsey, and originally published in 
the American Journal of Pharmacy. 

Doses are also ordered in teaspoonful, dessertspoonful, and table- 
spoonful quantities. Sometimes they are given by the wineglassful, 
meaning by this term a sherry-glassful. Roughly estimated, a tea- 
spoonful equals a fluidrachm (4.0), a dessertspoonful two fluidrachnis 
(8.0), and a tablespoonful half a fluidounce (15.5). As spoons and 
wineglasses vary considerably in capacity, it is always best to use a 
graduated medicine glass, such as is shown in Figs. 2, 3, and 4. 

ABSORPTION OF DRUGS. 

Knowledge of the rapidity with which certain drugs are absorbed 
from the various surfaces with which they come in contact is of im- 
portance in order that we may know when to repeat the dose if the 
first amount does not produce the desired effect. The rapidity of 
absorption depends upon a number of factors. 

Physiological Factors. — If the circulation is active, absorption is 
rapid ; but if it be depressed, absorption is slow. Thus, in a person ap- 
parently drowned, absorption may not occur at all until the vital func- 
tions are restored, and repeated doses given to the patient while un- 
conscious, acting together, may in the end poison him. This is often 
the case in delirium tremens when hypodermic injections of morphine 
are given or when the drug is administered by the mouth. In dropsy 
absorption is peculiarly slow, and a medicine may remain in the tissues 
for days, only to be absorbed with the exudate after severe purgation, 
profuse diuresis, or tapping. In cases of general dropsy hypodermic 
medication is nearly always worse than useless. 

When the stomach or bowel is empty absorption from either is 
rapid, but when they are full it is very slow. . In this fact we find 
the reason for the popular idea that a drink of whisky taken when a 
man is hungry makes him drunk, whereas twice that quantity after a 
meal does not do so. 

Drugs in the stomach or bowel have no influence upon the general 
system unless they are irritants. They only act when taken into the 
blood or lymphatics. When the stomach is atonic and its powers of 
absorption impaired, the addition of some irritant or stimulant, such as 
capsicum, will often aid in the absorption of the necessary drug. 

Physical Factors. — The physical characteristics of a drug greatly 
affect the rapidity of its absorption. Thus, the more volatile, diffusible, 
and soluble the medicament, the greater the speed with which it will 
enter the circulation. Two solutions belonging to the same group of 
chemical compounds may be utterly different in their action because 
of their physical state, as, for example, the volatile hydrocarbon pental, 
which is absorbed with great rapidity, and the non- volatile paraffin, 
which, although it belongs to the hydrocarbons, is entirely without 
physiological effect. 



COMBINATION OF DRUGS FOR JOINT EFFECT. 45 

Recent studies show that alcoholic solutions of drugs are more 
rapidly absorbed than are watery solutions or those made with 
glycerin or milk. 

DURATION OF ACTION OF DRUGS. 

The duration of the action of drugs depends partly upon their 
rapidity of absorption, but chiefly upon the rapidity or slowness of 
their decomposition or destruction in the body and their elimination 
from it. Thus, volatile substances, such as ether, chloroform, and 
nitrite of amy], act only for a short time and are quickly eliminated ; 
whereas bromide of potassium and digitalis continue active during 
many hours, and are slowly eliminated, as in the case of the former, 
or oxidized, as in that of the latter. Again, if curare is given hypo- 
derm ically it will cause paralysis, but if taken by the stomach in 
moderate amount it will be eliminated by the kidneys as rapidly as it 
is absorbed, and produce no effects if these organs are active. 

So, too, if a patient's kidneys are healthy, very large' doses of the 
potassium salts are harmless; but if he suffers from nephritis so 
that the potash is not rapidly eliminated they become dangerous 
depressants. 

From studying the rapidity of the elimination of a drug we learn 
how often to order a dose. Thus, digitalis may be given once, twice, 
or thrice a day, but carbonate of ammonium must be given every 
two or three hours to maintain its effects. 

When the physician is not careful in the use of a potent drug which 
is eliminated slowly, it may suddenly develop so severe an effect as to 
cause alarm, owing to its accumulation in the body. This is called 
" cumulative action/' 

COMBINATION OF DRUGS FOR JOINT EFFECT. 

The study of the physiological action of drugs has aided very 
greatly in improving our therapeutic measures. Thus, we now know 
that chloral is a heart-depressant and cannot be used in very full 
doses, or pushed to produce sleep in persistent insomnia, without 
grave danger ; whereas morphine, which also produces sleep but does 
not depress the heart, but does depress the respiration, can be com- 
bined with it, and the two acting together, each in small dose, produce 
a heavy sleep, although so little chloral is present that the heart is 
safe, and so small an amount of morphine is used that the respiration 
does not suffer. 

Another example of this is found in certain purgative pills in which 
the purgative agent is assisted by belladonna and nux vomica, the 
first of which relaxes muscular spasm, while the second acts as a tonic 
to the alimentary tract, the drugs combining to accomplish one result. 

Skill in the combination of drugs, not only for increased physiolo- 
gical effect, but also for the purpose of making their administration 
pleasant to the taste, has much more to do with professional success 



46 GENERAL THERAPEUTICAL CONSIDERATIONS. 

than is generally supposed. This is particularly so in regard to chil- 
dren, for parents dislike forcing their children to take doses which 
they themselves regard as unpleasant, and they are ever ready to 
believe that as long as a medicine tastes good it is better than one 
which tastes otherwise. 

The medical practitioner who prescribes never so wisely and appro- 
priately for a patient, but who is utterly regardless as to his combi- 
nations of drugs so far as taste is concerned, will soouer or later see a 
more ignorant man take from him that practice which his greater 
wisdom entitles him to, but which is driven from him by his own 
errors in this matter. 

While in some cases there is no alternative but to give an unpleas- 
ant dose, in others a little thought and care will often avoid offending 
the taste of the patient. 

STRENGTH AND RELIABILITY OF DRUGS. 

If a census- could be made of those who die annually from the use 
of drugs which are impure or useless from weakness, the writer be- 
lieves that a most alarming array of figures would be presented. For 
many years this was unavoidable to a great degree, either because our 
knowledge of the active principles of drugs and the methods of 
isolating them was deficient, or because the time consumed in their 
transportation by sailing vessels or on the backs of natives from the 
countries in which the natural products yielding the drugs were ob- 
tained, permitted deterioration to take place. At present these diffi- 
culties have been largely overcome. The trained pharmacist is 
taught how to make an assay for active principles in most of the valu- 
able alkaloidal drugs, and every physician should make careful 
investigation into the quality of all preparations which he employs. 
As an illustration of this matter the following facts are of interest. 
An intimate friend of the writer bought from five of the leading 
druggists of Philadelphia six ounces of tincture of mix vomica 
which were stated to have been made according to the directions 
of the United States Pharmacopoeia. That made by perhaps the 
leading druggist of the five contained twice as much strychnine and 
brucine as it should, and had twice as much solid residue ; or, in other 
words, a physician prescribing this tincture in full dose would prob- 
ably have poisoned his patient and reported the case as one of un- 
usual susceptibility to drugs ! On the other hand, the author has seen 
a tincture of nux vomica which contained only a trace of alkaloid, 
but had much inert solid residue. In neither instance was the drug- 
gist dishonest intentionally, but one had used a crude drug which was 
unusually rich in alkaloids, while the other had purchased nux vomica 
beans which, by reason of immaturity, bad surroundings, or exposure 
to weather, were very poor in active principles. Such an uncertainty 
as to the strength of this particular product is now prevented by the 
directions of the U, S. Pharmacopoeia, but the illustration as to 



IDIOSYNCRASY. 47 

many other drugs still holds good. All these disadvantages may 
be avoided if physicians will insist that the druggists who dispense 
the drugs they order shall either themselves prepare assayed pro- 
ducts, or purchase such products from any one of the large manu- 
facturing chemists who put assayed goods on the market. When this 
is impossible, the physician should employ the alkaloids in pill form, 
or, if solutions are desirable, the alkaloid may be added to alcohol or 
water and given by drops, as is the case with any ordinary tincture. 
Digitalis, veratrum viride, and ergot are practically the only drugs of 
importance of which an assay cannot be made ; in the first and third 
the action of the drug does not depend upon a single active principle, 
but upon a number difficult of assay, and in the second the relative 
proportions of jervine and protoveratrine cannot well be estimated. 
All drugs should be physiologically tested when their chemical assay is 
impossible. Not long since several thousand pounds of ergot were 
found to be worthless on being tested physiologically by one firm ; 
but it was put upon the market nevertheless, for certain manufactur- 
ers do not employ this method of examination. Constant uncertainty 
as to the strength of a drug is a dangerous element when dealing with 
patients who are desperately ill ; and in many cases failure and dis- 
couragement will both be avoided if the physician will see to it that 
the drugs which he administers are capable of doing what he requires 
of them. A poor drug to the physician is worse than a poor knife to 
the surgeon ; for the failure in the one case is unknown, while in the 
other it can be carefully watched and guarded. 

IDIOSYNCRASY. 

This is one of the most interesting features of the study of the action 
of drugs. It is a frequent cause of disappointment to both patient 
and physician, and an equally frequent cause of excessive action from 
what the medical attendant has thought to be a moderate dose. No 
rule can be laid down for the discovery of idiosyncrasy in a given case, 
except that females, particularly of the hysterical type, are more sub- 
ject to it than are males, although certain men often present marked 
evidences of this tendency. No better illustration of idiosyncrasy can 
be adduced than the case which here follows, nor than that of a friend 
of the author who cannot eat a strawberry without suffering from a 
violent attack of hives. 

The first case is that of a woman of thirty years, suffering from a 
severe headache, who received an eighth of a grain of the hydrochlor- 
ide of pilocarpine, hypodermically, every twenty minutes, until 
nearly three-fourths of a grain was taken, without any evidence of 
its action either in salivary flow or sweat. But the tolerance of 
drugs did not stop here. Twenty drops of tincture of cannabis 
indica every four hours failing to relieve the pain, half-grain pills of 
the solid extract were ordered, two of which commonly affect a grown 
man most markedly. The extract had been proved to be active to 



48 GENERAL THERAPEUTICAL CONSIDERATIONS. 

other patients. In order to avoid any failure in absorption the pills 
were each cut in half before they were given, and forthwith adminis- 
tered, one every three hours, without any effect after ten had been 
taken. Twenty more of the pills from the same manufacturers, but 
from a different retailer, were now given, one every hour with the 
exception of a few irregularities in administration during the night, 
the entire twenty being swallowed between four o' clock one after- 
noon and two o'clock the next afternoon. The thirty pills (fifteen 
grains) were taken in less than forty-eight hours without producing 
a single physiological sign of the slightest character. That the doses 
were really swallowed would seem to be undoubted, for their admin- 
istration was carried out by a trained attendant, and their black color 
forbade their expulsion from the mouth on the bed without attracting 
attention. The hypodermic injections were given by the author, and, 
as the solution was used as fast as it was made, the patient must cer- 
tainly have received all of the pilocarpine. As there was daily an 
afternoon rise of temperature amounting to several degrees, quinine 
bisulphate was ordered in the dose of fifteen grains, to be given after 
six powders of one-sixth of a grain of calomel had been taken ; this 
not only failed to control the fever, but also produced no buzzing in 
the ears. The writer was now inclined to consider all the symptoms 
as hysterical, even including the evening rise of temperature. Twenty- 
four hours after the last dose of cannabis indica the attendant gave 
the patient, without orders, no less than sixty grains of antipyrine in 
sixteen hours without any physiological symptoms, and, under orders, 
she took from forty to fifty grains of bisulphate of quinine every day 
for three days without any signs of cinchonism. 

Wide experience has taught us, however, that several conditious 
act fairly constantly in regard to some idiosyncrasies. Certain dis- 
eased conditions — such as peritonitis or pain — allow large doses of 
opium to be given, and in lead poisoning and paralysis patients may 
require enormous doses of active purgatives without moving the bowels. 

The climate in which the patient lives, or has been accustomed to 
live, renders him more or less susceptible to certain remedies. Thus 
the East Indian runs amuck after eating hasheesh or cannabis indica, 
or the Chinaman goes into a delightful dreamland from smoking 
opium, whereas the Anglo-Saxon experiences no such agreeable sen- 
sation, as a general rule. Southerners generally require larger doses of 
purgatives than Northerners, often because their livers are not so active. 

The temperament of an individual is also a highly important matter 
to be considered. It is a notorious fact that phlegmatic dark-skinned 
individuals usually yield to drugs less readily than blondes and ner- 
vous persons, more especially in respect to the drugs which act on the 
nervous system. Nervous light-haired women stand belladonna very 
badly as a general rule, while children will take large doses often 
without discomfort. Opium is usually badly borne by children. 

Habit is another important factor governing idiosyncrasy. We all 



INDICATIONS, CONTRAINDICATIONS, AND DEFINITIONS. 49 

know how rapidly one becomes accustomed to tobacco and how morphine 
habitues take enormous amounts of their favorite drug without effect. 

INDICATIONS, CONTRAINDICATIONS, AND DEFINITIONS. 

The indication for a drug is any symptom or condition., or series 
of symptoms or conditions, which we know the drug will relieve 
without causing at the same time an evil effect to be felt by other 
parts of the body. A contraindication is any coexisting state or 
tendency which will be made so much worse by the drug as to forbid 
its use. Thus, one might be tempted to give quinine in meningitis 
for the fever, yet this would be bad therapeutics, since quinine is 
contraindicated because it will increase the meningeal congestion. 

Abortifaeients form a class of drugs which, as such, ought never to 
be employed. If pregnancy is to be interfered with, the interruption 
should be produced by instrumental means, and then only after con- 
sultation with another practitioner to get his views and protect one's 
self from possible legal difficulties. 

Alteratives are indicated where cell-growth is active to excess, but 
contraindicated where tissue break-down is present, or when there 
exists a tendency thereto. 

Anaesthetics are used to abolish sensation. They are either local or 
general. Many of the local anaesthetics produce loss of sensation 
through benumbing the parts by the cold they produce. Cocaine 
is an example of a local anaesthetic which causes anaesthesia by a di- 
rect paralyzant action on the peripheral sensory nerves. The general 
anaesthetics are taken by inhalation and act upon the higher centres 
in the brain. 

Anaphrodisiacs are used to diminish sexual desire. 

Aphrodisiacs are used to increase sexual desire and power. 

Antacids are employed in cases iu which, as a result of morbid pro- 
cesses, lactic and butyric acids, or even hydrochloric acid, are found 
in abnormal quantities in the stomach. 

Anthelmintics are used for the purpose of removing intestinal worms. 

Antiarthritics is the name given those drugs Avhich are employed 
for the purpose of relieving inflammations occurring in joints, whether 
these be in an acute or chronic condition of disease. 

Antihydrotics are used to prevent excessive sweating, either local 
or general. Camphoric acid is probably the best general antihydrotic. 

Antiperiodics is a term applied to drugs or remedies employed for 
the prevention or cure of malarial poisoning. They are so named 
because they tend to diminish or arrest the periodicity of the attacks, 
which periodicity is a characteristic of such diseases. 

Antiphlogistics are employed to prevent the progress of inflamma- 
tory processes. They are nearly all contraindicated in the presence 
of tissues possessing impaired vitality through previous conditions of 
disease. 

Astringents are employed for the purpose of contracting or con- 
4 



50 GENERAL THERAPEUTICAL CONSIDERATIONS. 

stringing tissues. They act either by coagulation of albumin, by 
percipitating albumin, or by making the tissues more dense by con- 
centration. Theoretically, all astringents should be non-irritating, but 
practically they possess irritant properties, and are, in consequence, 
contraindicated in the presence of very acute inflammations as a rule. 
Three of the mineral astringents, however, possess marked sedative 
properties in addition to their astringent power, and can therefore be 
used freely in acute inflammation when locally applied. They are 
nitrate of silver, subacetate or acetate of lead, and the subcarbonate 
or subnitrate of bismuth. 

Bitters are designed to increase the activity of the mucous mem- 
brane of the gastro-intestinal canal by increasing its tone. They 
may be divided into simple bitters and complex bitters. The first 
depend upon their bitterness solely for their activity ; the second class 
is well represented by quinine and strychnine, both of which are 
exceedingly bitter, but, in addition to their local effect on the gastro- 
intestinal mucous membrane, act as stimulants to other portions of the 
organism. A good example of a simple bitter is columbo. Many 
bitters coutain so much tannic acid that they are not generally useful, 
and for this reason very few can be used with preparations of iron, 
since a tannate of iron would be formed. 

Cardiac sedatives decrease the force of the heart, and, as a class, the 
amount of blood expelled at each beat of the ventricles. They are indi- 
cated in arterial excitement and contraindicated in arterial depression. 

Cardiac stimulants increase the force of the heart, thereby increas- 
ing the quantity of blood expelled from the ventricles. Their effect 
may be accomplished by an increase in the rapidity of the beats or 
by a greater output of blood at each contraction, the diastole being 
sufficiently prolonged to admit of the ventricles being well filled. 
They are contraindicated in the presence of arterial excitement, and 
indicated in arterial depression. 

Carminatives are given for the purpose of expelling flatus, particu- 
larly if there is reason to believe that the "wind" has accumulated 
because of intestinal torpidity. Many of the carminatives are neces- 
sarily possessed of irritant properties, and are therefore contraindicated 
in the presence of flatulence due to intestinal atony arising from 
inflammation. The best carminative is spiritus setheris compositus, 
or Hoffmann's Anodyne. 

Cathartics. — These are drugs employed when a positive and decided 
action of the bowels is desired. They occupy a position between the 
purges and the drastics. (See Purges and Drastics.) A good exam- 
ple of a cathartic is senna when given in full dose. 

Cholagogues are used to exert a stimulant influence over the flow of 
bile. Nitrohydrochloric acid and mercury bichloride are perhaps 
the best types of pure cholagogues, while podophyllum and calomel 
represent the class of cholagogues which increase intestinal peristalsis 



INDICATIONS, CONTRAINDICATIONS, AND DEFINITIONS. 51 

in addition to stimulating the flow of bile. Cholagogues are, as a rule, 
contraindicated in the presence of acute inflammation of the gall- 
bladder or liver. 

Counterirritants are used to produce irritation at a spot distani 
from a painful or inflamed area, in order to relieve the diseased parts 
by reflex action exerted through the nervous system upon the painful 
nerve or disordered capillary network. 

Demulcents are used to protect from irritation any exposed parts 
of the body. 

Diaphoretics produce an increased secretion from the sweat-glands. 
They may be considered as internal and external. The internal are 
represented by pilocarpine, which stimulates the sweat-glands them- 
selves; the external are represented by the Turkish and Russian baths 
which, by increasing bodily heat and dilating bloodvessels, cause a 
profuse sweat. 

Diuretics are used to increase the flow of urine from the kidneys. 
They act by stimulating the renal epithelium to greater activity, 
thereby increasing the excretion of both the watery and solid con- 
stituents of the urine ; or they simply increase the watery constituents 
by increased blood-pressure in the kidney. 

It is to be remembered that the vegetable salts of potassium and 
the lithium salts increase the solids in the urine, not by stimulating 
the secreting epithelium of the kidney, but by uniting with insoluble 
material in the system, forming soluble compounds which are then 
readily eliminated. (See Eliminators.) They are indicated in con- 
ditions of renal inactivity due either to functional or organic causes. 
Irritating diuretics, such as cantharides, for example, are contraindi- 
cated in acute nephritis. Such a diuretic is only to be used where 
the kidneys are inactive through atony or prolonged chronic or sub- 
acute disease. 

Eliminators are drugs which, by forming soluble compounds with 
insoluble substances in the body, render them capable of being 
excreted by the excretory organs, such as the skin, kidneys, and 

bowels. 

Emetics are used to produce vomiting. They act centrally when, 
as is the case with apomorphine, they stimulate the vomiting centre; 
peripherally when they irritate the walls of the stomach. They are 
indicated when we wish to unload the stomach of undesirable ma- 
terials, or when we desire to cause an increased flow of bile from the 
gall-bladder, which is accomplished by the pressure exerted upon 
this viscus when the abdominal walls and diaphragm contract in 
retching. 

When the ducts are mechanically obstructed by a gallstone emetics 
are dangerous, as they may cause rupture of the gall-bladder. 

Sometimes we are able by the use of emetics to rid the lungs and 
stomach of mucus in bronchitis or gastric catarrh. 



52 GENERAL THERAPEUTICAL CONSIDERATIONS. 

The contraindications to emetics are cerebral congestion or menin- 
gitis, gastritis, gastric ulcer, advanced pregnancy, and hernia. 

Emmenagogues are used to produce or increase the menstrual flow. 

They are of two classes-direct and indirect. The direct are most 
of them irritants, and are seldom of much value ; the indirect are 
used to overcome the morbid condition underlying the menstrual dis- 
order, and are therefore more rational. Thus iron and arsenic may 
be used with beneficial result in amenorrhoea due to ansemia. 

Expectorants are employed when it is desirable to promote secretion 
or to get rid of secretion in the bronchial tubes. Thus, in the early 
stages of an acute bronchitis the mucous membrane is hypersemic and 
swollen, but dry and irritable. Ipecac and citrate of potassium form 
at this time a sedative expectorant mixture, which, while allaying 
irritation, promotes secretion and so relieves the engorged area. On 
the other hand, after the acute stage is passed, there may be so much 
atony of the mucous glands that the secretion is either too scanty or 
too viscid to be coughed up. Stimulant expectorants, such as chloride 
of ammonium, eucalyptus, and terebene, are now to be employed. 
These latter drugs are contraindicated in the acute inflammatory stage 
of the disease, as they would simply stimulate the mucous membrane 
to greater irritation. 

Hypnotics are used to produce sleep. They may be divided into 
those which produce sleep and relieve pain, and those which have no 
analgesic power. The latter are therefore not to be employed in 
sleeplessness due to pain, and the former are contraindicated when 
pain is absent. Thus, hydrated chloral produces sleep, if it be ordi- 
nary functional insomnia ; but if the sleeplessness is due to pain, 
opium is the drug to be employed. Medinal or veronal sodium, in 
ordinary doses, is the purest hypnotic that we have. 

Mydriatics produce dilatation of the pupil, or mydriasis. Condi- 
tions of the eye associated with increased intraocular tension are con- 
traindications to mydriatics, as a rule. 

Myotics cause contraction of the pupil or myosis. They are best 
represented by eserine. 

Nervous sedatives are indicated and contraindicated in a reverse 
manner to nervous stimulants. 

Nervous stimulants are contraindicated in nervous excitement, and 
indicated in nervous depression. 

Oxytoxics increase the expulsive power of the uterine muscle. 

Revulsives are used to produce increased activity of the general 
system or parts thereof through reflex influences — that is, they cause 
a determination of blood to one part, thereby relieving an engorged 
area. Thus, in cerebral congestion or effusion a vigorous purgative 
or cathartic may give relief by exercising a derivative effect. Revul- 
sives are closely allied to counterirritants. 

Roborants are devoted to the repair and building up of tissues in 
the body, and comprise both food and drugs. Roborant treatment 



CLASSIFICATION OF DRUGS. 



53 



also includes hygienic surroundings, fresh air, light and healthful 
employment. 

Tonics are used to increase vital activity. They are indicated in local 
or general systemic depression and contraindicated in cases of inflam- 
mation or excitation with excessive functional activity. (See Bitters.) 

Vasomotor depressants decrease arterial pressure by an action on the 
vasomotor nervous system rather than by an action on the heart. 
They act by relaxing the bloodvessels. 

Vasomotor stimulants increase arterial pressure by an action on the 
vasomotor system, thereby producing contraction of the bloodvessels. 

CLASSIFICATION OF DRUGS. 



In order that the student may gain a definite idea as to the 
various actions of different remedies the following list of drugs is 
appended, which is of necessity somewhat arbitrary and is not in- 
tended to be exhaustive, for many remedies might be placed in several 
classes. The endeavor has been made to place the best or most 
powerful drug of each class first in the list. It is to be remembered 
that a strict physiological classification is impossible. 



I. Alteratives. 

1. Mercury. 

2. The iodides of potassium and 

sodium. 

3. Iodine. 

4. Iodoform. 

5. Iodol. 

6. Arsenic. 

7. Cod-liver oil. 

8. Colchicum. 

9. Ichthyol. 

10. Taraxacum. 

11. Mezereum. 

II. Anaesthetics. 

1. Ether. 

2. Nitrous oxide gas. 

3. Chloroform. 

4. Cocaine. 

5. Eucaine. 

6. Bromide of ethyl. 

7. Chloride of ethyl and of methyl. 

8. Pental. 

9. Bromoform. 

10. Phenol. 

11. Antipyrine. 

12. Menthol. 

III. Antacids. 

1. Ammonia. 

2. Sodium and its salts. 

3. Liquor potassii hydroxidi. 

4. Magnesia. 

5. Lime. 

IV. Anthelmintics. 

Those that are used against the round- 
worm are — 

1. Santonica. 

2. Spigelia. 

3. Chenopodium. 

4. Azedarach. 

5. Santoninate of sodium. 



Those used against the tape-worm 
are — 

1. Pelletierine. 

2. Aspidium. 

3. Pepo. 

4. Pomegranate. 

5. Brayera. 
G. Kamala. 

7. Turpentine. 

8. Chloroform. 

Those used against the seat worm, oi 
Oxyuris vermicularis, are — 

1. Quassia. 

2. Turpentine. 

3. Tannic acid. 

4. Sodium chloride. 

5. Vinegar. 

V. Antiseptics. (See also Disinfect- 

ants. ) 

1. Corrosive sublimate in weak 

solutions. 

2. Phenol (carbolic acid.) 

3. Peroxide of hydrogen. 

4. Creolin. 

5. Lysol. 

6. Boric acid. 

7. Permanganate of potassium. 

8. Salicylic acid. 

9. Sulphate of iron. 

VI. Antiperiodics or Antimalarials 

1. Cinchona. 

2. Eucalyptus. 

3. Warburg's tincture, 

4. Arsenic. 

5. Methylthionine hydrochloride 

(methylene blue.) 



54 



GENERAL THERAPEUTICAL CONSIDERATIONS. 



VII. Antipyretics. 

1. Antipyrine. 

2. Acetanilide or antifebrin. 

3. Acetphenetidin (phenacetin.) 

4. Guaiacol. 

5. Phenocoll. 

6. Quinine. 

7. Salicylic acid. 

8. Phenol (carbolic acid). 

VIII. Antispasmodics. 

1. Amyl nitrite. 

2. Hydrated chloral. 

3. Bromides. 

4. Opium. 

5. Belladonna. 

6. Camphor. 

7. Hoffmann's anodyne. 

8. Asafcetida. 

9. Musk. 

10. Valerian. 

11. Monobromated camphor. 

12. Amber. 

13. Cimicifuga. 

14. Hops. 

IX. Astringents. 
Vegetable : 

1. Tannic acid. 

2. Haematoxylon. 

3. Kino. 

4. Gambir. 

5. Rhatany or krameria. 

6. Rhus glabra. 

7. Geranium. 

8. White oak. 

9. Black oak. 

10. Gallic acid. 

11. Rosa centifolia. 
Rosa gallica. 



12. 



All of these depend chiefly upon tan- 
nic acid for their active principle. 
Mineral : 

1. Sulphuric acid. 

2. Alum. 

3. Lead. 

4. Nitrate of silver. 

5. Nitric acid. 

6. Sulphate of copper. 

7. Bismuth. 

8. Sulphate of zinc. 

X. Cardiac Sedatives. 

1. Aconite. 

2. Veratrum. 

3. Antimony. 

4. Hydrocyanic acid. 

5. Veratrine. 

XI. Cardiac Stimulants. 

1. Digitalis. 

2. Strophanthus. 

3. Ammonia. 

4. Ether. 

5. Alcohol. 

6. Caffeine. 

7. Nux vomica. 

8. Ignatia. 

9. Adonis vernalis. 

10. Convallaria majalis. 

11. Sparteine. 

12. Amyl nitrite (momentarily). 

13. Opium. 



XII. Counter-irritants. 

Those counter-irritants that blister 
are called epispastics. They are — 

1. Cantharides. 

2. Thapsia. 

3. Ammonia or chloroform when 

under a watch-glass. 

Those that redden or produce local 
hyperaemia of the skin are— 

1. Mustard. 

2. Capsicum. 

3. Turpentine. 

4. Ammonia. 

5. Chloroform. 

6. Burgundy pitch. 

7. Canada pitch. 

8. Most of the spices. 

Under the name of Escharotics are 
grouped a number of substances 
capable of acting as destructive 
agents upon the soft tissues of the 
body. They are— 

1. Chromium trioxide (chromic 

acid ) . 

2. Nitric acid. 

3. Sulphuric acid. 

4. Nitrate of mercury (solution). 

5. Bromine. 

6. Potassium hydroxide. 

7. Sodium hydroxide. 

8. Burnt alum. 

9. Arsenic trioxide. 

10. Chloride of zinc. 

11. Vienna paste. 

12. Canquoin's paste. 



XIII. Diaphoretics. 

The only ones that we know as direct 
stimulants to the glands are — 

1. Pilocarpus or jaborandi. 

2. Warburg's tincture. 



The others are — 

3. Hot dry and hot moist baths. 

4. Dover's powder. 

5. Alcohol (particularly when 

hot). 

6. Nitrous ether. 



XIV. DlGESTANTS. 

1. Pancreatin. 

2. Pepsin. 

3. Hydrochloric acid. 

4. Diastase. 

5. Papain. 

XV. Disinfectants. 

1. Corrosive sublimate. 

2. Chlorine or chlorinated lime. 

3. Formaldehyde. 

4. Phenol. 

5. Chloride of zinc. 



CLASSIFICATION OF DRUGS. 



55 



XVI. Diuretics. 

Those that increase both the solids 
and liquid constituents are proba- 
bly— 

1. Caffeine. 

2. Squill. 

3. Cantharides. 

4. Buchu. 

5. Vegetable salts of potassium. 

6. Lithium. 

7. Juniper. 

8. Turpentine, 

9. Uva ursi. 

10. Chimaphila. 

11. Cubebs. 

12. Pareira brava. 

Those which increase the watery por- 
tion of the urine without increas- 
ing the solids proportionately are — 

1. Digitalis. 

2. Strophanthus. 

3. Apocynum. 

4. The Nitrites. 

XVII. Eliminatives. 

1. The iodides. 

2. The salicylates. 

3. The vegetable salts of potas- 

sium and the purgatives. 

4. The lithium salts. 

5. Jaborandi. 

6. Colchicum (probably). 

XVIII. Emmenagogues. 

The direct emmenagogues are — 

1. Apiol. 

2. Dioxide of manganese. 

3. Permanganate of potassium. 

4. Cantharides. 

5. Aloes. 

6. Myrrh. 

7. Rue. 

8. Savine. 

9. Tansy. 

10. Pennyroyal. 

11. Guaiac. 

The indirect are — 

1. Iron. 

2. Arsenic. 

3. Copper. 

4. Tonics in general. 

XIX. Emetics. 

The direct are represented by — 

1. Apomorphine. 

2. Ipecac (which is both centric 

and peripheral). 

3. Tartar emetic (which is both 

centric and peripheral). 

The peripheral are — 

1. Sulphate of zinc. 

2. Mustard. 

3. Alum. 

4. Sulphate of copper. 

5. Turpeth mineral. 

XX. Expectorants. 
Sedatives : 

1. Citrate or acetate of potassium. 

2. Ipecac. 

3. Antimony. 

4. Lobelia. 



Those which act as stimulating ex- 
pectorants are — 

1. Ammonium chloride. 

2. Apomorphine. 

3. Creosote. 

4. Eucalyptus. 

5. Tar. 

6. Terebene. 

7. Terpine hydrate. 

8. Oil of sandal-wood. 

9. Sulphur. 

10. Grindelia robusta. 

11. Garlic. 

12. Squill. 

Besides these we have nux vomica, 
which increases expectoration by stim- 
ulating the nervous system to coughing, 
and thus expels the mucus. Opium and 
the bromides depress the nervous sys- 
tem and allay cough, and so decrease 
expectoration. 

XXI. Hypnotics. 

1. Veronal sodium or medinal. 

2. Veronal. 

3. Sulphonethylmethane (trional). 

4. Sulphonmethane (sulphonal). 

5. Chloral hydrate. 

6. Bromides of potassium, sodium, 

etc. 

7. Opium. 

8. Tetronal. 

9. Paraldehyde. 

10. Chloralose. 

11. Chloralformamide ( chlorala- 

mide). 

12. Hypnal. 

13. Hyoscine (in mania). 

14. Duboisine (in mania). 

15. Cannabis indica (in large dose). 

XXII. Nervous Sedatives. 

1. Hydrated chloral. 

2. Opium (in full doses). 

3. The bromides and hydrobromic 

acid. 

4. Chloroform. 

5. Amyl nitrite. 

6. Nitrites of potassium and sodi- 

um and nitroglycerin. 

7. Ether. 

8. Bromide of ethyl. 

9. Nitrous oxide. 

10. Bromoform. 

11. Belladonna. 

12. Antipyrine. 

13. Acetanilide. 

14. Acetphenetidin (phenacetin). 

15. Calabar bean. 

16. Hydrocyanic acid. 

17. Lobelia. 

18. Conium. 

19. Cannabis indica. 

20. Sulphonmethane (sulphonal). 

21. Croton chloral. 

22. Paraldehyde. 

23. Camphor. 

24. Monobromated camphor. 

25. Asafcetida. 

26. Amber. 

27. Hoffmann's anodyne. 

28. Cimicifuga. 



<56 



GENERAL THERAPEUTICAL CONSIDERATIONS. 



29. Musk. 

30. Valerian. 

31. Humulus. 

32. Castor. 

33. Hypnal. 

XXIII. Nervous Stimulants. 

1. Nux vomica. 

2. Ignatia. 

3. Coca. 

4. Kola. 

5. Caffeine. 

XXIV. Oxytocics. 

1. Pituitrin. 

2. Ergot. 

3. Cotton-root. 

4. Ustilago maydis. 
And indirect when in labor. 

1. Quinine. 

2. Kola. 

XXV. Purgatives. 
Laxatives: 

1. Rhamnus purshiana (cascara 

sagrada). 

2. Aloes. 

3. Phenolphthalin. 

4. Sulphur. 

5. Rhubarb. 

6. Frangula. 

7. Cassia fistula. 

8. Euonymus. 

9. Magnesium oxide (magnesia). 

10. Manna. 

11. Fruits. 

Cathartics (mineral) : 

1. Magnesium sulphate. 

2. Magnesium citrate. 

3. Sodium phosphate. 

4. Potassium and sodium tartrate. 

5. Sodium sulphate. 

6. Mercury. 

Cathartics (vegetable) : 

1. Castor oil. 

2. Senna. 6 

3. Podophyllin. 



Cathartics (hydragogue) : 

1. Elaterium. 

2. Jalap. 

3. Colocynth. 

4. Croton oil. 

5. Gamboge. 

6. Scammony. 

7. The saline purgatives, if con- 

centrated solutions are used. 

XXVI. Tonics. 

1. Cinchona. 

2. Nux vomica. 

3. Calumba. 

4. Arsenic. 

5. Phosphorus. 

6. Mercury (in minute doses). 

7. Copper. 

8. Iron. 

9. Hydrochloric acid. 

10. Nitro-hydrochloric acid. 

11. Nitric acid. 

12. Phosphoric acid. 

13. Condurango. 

14. The vegetable bitters in gen- 

eral. 

XXVII. Vasomotor Depressants. 

1. Amyl nitrite. 

2. Nitroglycerin and other ni- 

trites. 

3. Veratrum. 

4. Antimony. 

5. Aconite. 

6. Alcohol (in excessive doses). 

7. Jaborandi. 

XXVIII. Vasomotor Stimulants. 

1. Belladonna. 

2. Pituitrin. 

3. Suprarenal gland. 

4. Digitalis. 

5. Nux vomica. 

6. Ergot. 

7. Caffeine. 

8. Convallaria. 



INCOMPATIBILITY. 

One of the uses of a knowledge of chemistry and pharmacy to a prac- 
titioner of medicine is the avoidance of what is known as an "incom- 
patibility," or the placiug in a prescription of two or more substances 
which will undergo chemical interchanges, decompositions, precipita- 
tions, or cause the formation of explosive mixtures. It is impossible 
in this book to detail all the incompatibilities, and only the most 
dangerous and common possibilities of error can be considered : 

1st. An acid should never be combined with an alkali. 

2d. A strong acid should not be added in any quantity to a tincture. 
The following prescription is an illustration of this : 

fy— Potassii iodidi 5ij. 

Acidi nitro-hydrochlorici f3j. 

Tincturse cinchonas compositae ....... q. s. fgiij.— M. 

S. —Use as directed : a teaspoonful. 



INCOMPATIBILITY. 57 

In this ridiculous mixture the acid is incompatible with the iodide 
of potassium, forming a chloride and setting free iodine, and would 
also change part of the alcohol in the tincture into an ether. 

3d. Alkalies and neutral bases should not be combined with the 
alkaloidal salts. 

fy— Strychninae sulphatis gr. j. 

Potassii iodidi 3ij. 

Syrupi sarsaparillae compositi f^iij- — M. 

S. — Teaspoonful t. i. d. 

In this prescription the strychnine would be precipitated by the 
potassium salt, and the patient would get nearly all the stryehniue m 
the last dose. 

4th. Potassium chlorate should not be ordered to be rubbed up with 
tannic acid nor any other organic substance capable of oxidation, as it 
will explode. Permanganate of potassium is subject to the same rule. 

5th. Chlorate of potassium and ammonium chloride when mixed 
together may ignite. 

6th. Iron is incompatible with tannic acid, as it forms a tannate of 
iron, or ink. As all the vegetable astringents contain tannic acid, 
they should none of them be used with iron except columbo and 
quassia. 

7th. Tannic acid should never be added to solutions of alkaloids. 

8th. Gum arabic is not to be added to solutions of iron, lead, or 
the mineral acids. 

9th. Alcoholic solutions of camphor and similar resinous substances 
are incompatible with water. 

10th. Most fluidextracts are incompatible with water, as the addi- 
tion of water will precipitate them. 

11th. All salts not acid but alkaline in reaction are decomposed by 
acids. 

12th. All salts which are acid are decomposed by alkalies. 

13th. All vegetable acid salts are altered by mineral acids and are 
decomposed by alkalies. 

14th. Iodine and the iodides should not be given with alkaloids. 

loth. Corrosive sublimate, the salts of lead, iodide of potassium, and 
nitrate of silver should always be prescribed alone, except in the follow- 
ing instances : 

(a) Corrosive sublimate may be given with potassium iodide, since 
it will throw down a precipitate which redissolves and forms a double 
salt. 

(6) Nitrate of silver may be used with extract of opium or hyoscya- 
mus. 

16th. Syrup of squills should not be given with the carbonate of 
ammonium, as it contains acetic acid. Chloride of ammonium is not 
incompatible with it. 

1 7th. Cherry-laurel water should not be prescribed with morphine, 
as it may form the poisonous cyanide of morphine. 



58 GENERAL THERAPEUTICAL CONSIDERATIONS. 

18th. Chloral and cyanide of potassium should never be placed in 
the same prescription, as they will decompose each other, setting free 
hydrocyanic acid. 

19th. Cocaine aud borax when added together form an insoluble 
borate of cocaine. Boric acid and cocaine do not result in this for- 
mation. 

20th. Calomel and antipyrine are incompatible, as are also sweet 
spirit of nitre and antipyrine. 

2 1 st. Waters cannot be used in preparing saturated solutions of drugs, 
as they are already loaded with the volatile substance. 

2 2d. Pepsin and pancreatin should not be used together, since the 
former can only act in an acid and the latter in an alkaline medium, 
and the pancreatin is destroyed by the acid gastric digestive process. 
Further, one ferment may neutralize the other. 



THE IMPORTANCE OF DIETETIC TREATMENT. 

Many physicians fail to pay proper attention to the regulation of 
the diet when treating those who are ill or " out of sorts." As a 
matter of fact, the administration of medicine often fails to produce 
good results simply because the patient, by persisting in the use of 
improper food and drink, is perpetuating the difficulty of which he is 
trying to get rid. There is scarcely a case in which some regulation 
or alteration of the diet will not be of advantage to the sick man. 
(See Foods for the Sick.) Further than this, failure to give direc- 
tions as to diet is apt to give the patient the idea that the physician is 
careless, whereas care in this respeet will greatly enhance his estimate 
of the physician's ability to attend to important details of the case. 

PRESCRIPTION WRITING. 

When a physician directs a patient how to regulate his diet, what 
exercise he is to take, and how many hours a day are to be devoted to 
recreation and work, he prescribes for him quite as much as when he 
writes a prescription calling for one or more drugs which are to be 
dispensed by the druggist and swallowed by the individual who is 
ailing. Nevertheless, the word "prescription" is usually applied to 
the piece of paper on which is written the physician's order to the 
druggist. 

In writing prescriptions physicians usually employ Latin terms. 
There are several reasons for this. In the first place, it is a custom 
which has been followed since the time when medical science was in 
its infancy, and medical men were wont to write what they had to say 
in Latin. Secondly, the botanical names of plants are usually given in 
Latin : first, because scientific men give them their names, and, second, 
because not infrequently the English name for a plant in one part of 



PRESCRIPTION WRITING. 59 

a country has an entirely different application in another. Thus, 
nearly every State has a drug called "Snake-root," yet in each in- 
stance a different plant may be so designated. Again, it is often ad- 
visable that a patient be kept in ignorance of the character of the drug 
which he is taking, lest he attempt to use it without a physician's 
advice on another occasion, and thereby do himself injury. Thus 
the physician might wish to give a patient a dose of coca as a power- 
ful nervous stimulant, yet would fear that it might be taken without 
advice later, and do harm. By using the word " Erythroxylon " 
the druggist knows what to dispense, but the patient does not recog- 
nize the term used and fails to remember it. 

All prescriptions should be written on sheets of paper on which are 
printed the physician's name, address, and office hours. This infor- 
mation is obviously necessary, and particularly is it useful to the drug- 
gist, who may wish to communicate with the physician in case he 
thinks that a poisonous dose has been ordered by mistake. The 
name and address of the patient should be written on the prescrip- 
tion-blank, so that the druggist may know r where the medicine is to 
be sent when it is prepared. The prescription is to be accurately dated. 

The symbol or mark placed on a prescription-blank after writing the 
name of the patient and his address is " ~£y" which stands for " Reci- 
pe," which is the second person singular of the imperative present of 
the Latin verb " Recipio," meaning "I take." Recipe or 1^, there- 
fore, says to the druggist " Take thou " of whatever substances the 
physician desires. As he is to take a given quantity of his stock and 
place it in the mixture, the name of the drug is put in the partitive 
genitive case. When, however, a pill or other finished or complete 
product is ordered, so that not part of the stock, but the whole article 
is desired, the name of the medicine is placed in the accusative case, 
since it is the object of the verb. 

The nouns or names of drugs belong to one of the five Latin de- 
clensions, and are most of them declinable. Those of the first declen- 
sion end in the letter "a" in the nominative singular, and in "se" 
in the genitive singular, or "arum" in the genitive plural, ex- 
cept in the case of the word aloe, the genitive singular of which is 
aloes. Thus aqua is the nominative, aqace is the genitive singular, 
and aquarum is the genitive plural. 

The nouns of the second declension end either in "us" if mascu- 
line, or " um " if neuter. Their genitive singular ends in "i" and 
the genitive plural in " orum." There are several nouns of this 
declension which end in "on," like " hsematoxylon, " which also end 
in "i" in the genitive singular. Thus we find that Syrupus is the 
nominative, Syrupl the genitive singular, and Syruporum the genitive 
plural. 

In the third declension the nouns end in a, e, i, o, y, c, 1, m, r, s, t, 
and x. The genitive singular ends in "is" and the genitive plural 
in "um". Thus, JEther in the genitive is JEtheris, and the genitive 



60 GENERAL THERAPEUTICAL CONSIDERATIONS. 

plural JEtherum. When the noun ends in "s" the genitive takes a 
"t" before the "is." Thus boras is the nominative singular, bora- 
tis the genitive singular, and boratum the genitive plural. 

In the forth declension the masculine nouns end in " us," and the 
neuter nouns in " u." The genitive singular of the masculine noun 
ends, as does the nominative, in "us," and the neuter noun like the 
nominative ends in "u," while the genitive plural ends in "urn." 
Thus, Spiritus, of which the nominative singular ends in " us," is 
spiritus, in the genitive singular, and spirituum in the genitive plural. 

In the fifth declension the nominative singular ends in "es," the 
genitive singular in "i," and the genitive plural in "rum." Thus 
Res has as its genitive singular rei, and as its genitive plural rerum. 

Adjectives used to qualify nouns agree with them in gender, number, 
and case. 

After the ingredients and their quantities have been signified the phy- 
sician expresses his wishes further, and writes the word "Misce," 
"mix," the ingredients. If the prescription is put up in fluid form, 
he next writes the signatura, and writes the word Signa, usually abbre- 
viated by Sig.y which tells the druggist to write the directions, which 
follow in English, on the label of the bottle. 

If the prescription consists in a powder and is to be put up in papers, 
after the word Misce, or the letter " M." which stands for emisc, the 
physician adds et divide in chartulas No. xx. — that is, divide into 
tweuty small papers or powders. If pills are desired, he writes 
M. fiant (often written " ft.") pilules No. xx. — that is, make into 
20 pills. 

Or fiat unguentum, let an ointment be made. 

Or the imperative may be used by the employment of the word fac, 
as fete suppositorias numero v. — that is, "Make thou 5 suppositories." 

If capsules are desired, the druggist is directed to mix the ingre- 
dients, and the physician adds et pone in capsulas No. xx. — that is, 
mix and put into 20 capsules. 

A prescription is often composed of a basis or the drug that is 
most important, an adjuvant or the drug to aid the basis, a correc- . 
live to overcome some effect which is undesirable, and a vehicle to 
give bulk and to carry the active substances into the body. After 
the name of the vehicle, which is also designed to bring up the mix- 
ture to an even quantity, we add the words quantum sufficit ad (a 
sufficient quantity to), usually abbreviated to "q. s. ad," to make 
the number of ounces desired. 

A complete prescription may therefore be written as follows : 

For Mr. John Jones, 111 Bank Street. 
October 31, 1907. 

B;— Bismuthi subnitratis gr. xl. 

Creosoti - ^Ix. 

Misce et pone in capsulas No. xx. 
Signa. — Take one after each meal. 



PRESCRIPTION WRITING. 



61 



Or 

]^ — Acidi sulphurici aromatici f 3ij. 

Fluidextracti haematoxyli . , f5iv. 

Spiritus chloroformi f§j. 

Syrupi zingiberis „ q. s. ad fgiij. 

Misce. 
Signa.— Take 1 dessertspoonful in water every three hours. 

Id the last prescription the sulphuric acid is the basis, the hsema- 
toxvlon and spirit of chloroform are the adjuvant*, and the syrup of 
ginger is the vehicle. 



Latin Word. 


Abbreviation. 


Translation. 


Ad. 




To, up to. 


Ad lib'ituin. 


Ad lib. 


At pleasure. 


Adde. 


Add. 


Add (thou). 


Ana. 


A., aa. 


Of each. 


Aqua bul'liens. 


Aq. bull. 


Water, boiling. 


Aqua destilla'ta. 


Aq. dest. 


Water, distilled. 


Aqua fonta'na, fervens. 


Aq. font., ferv. 


Water, spring, hot. 


Aqua pluvia'lis. 


Aq. pluv. 


Water, rain. 


Aqua 'lis. 




Pertaining to water. 


Bene. 




W T ell. 


Bis in dies. 


Bis in d. 


Twice daily. 


Bulliat. bulliant. 


Bull. 


Let boil. 


Cape, capiat. 


Cap. 


Take. Let him take. 


Cap'sula. 


Caps. 


A capsule. 


Cera' turn. 


Cerat. 


A cerate. 


Char'ta (karta). 


Chart. 


A paper (medicated). 


Chartula (kartnla). 


Chart 


A little paper for a powder. 


Cibus. 


Cib. 


Food. 


Cochle'are magnum. 


Coch. mag. 


A tablespoon. 


Cochle'are parvuni. 


Coch. parv. 


A teaspoon. 


Cola, colatus. 


Col. 


Strain. Strained. 


Colluto'rium. 


Collut. 


A mouth-wash. 


OoDyr'ium. 


Collyr. 


An eye-wash. 


Compos'itus. 


Co., Comp. 


Compound. 


Confec'tio. 


Conf. 


A confection. 


Con'gius. 


C. 


A gallon. 




C.c. 


A cubic centimeter or cubic cen- 

timers. 


Cum. 




With. 


Dilute. Dilu'tus. 


Dil. 


Dilute (thou), diluted. 


Dim id 'i us. 


Dim. 


One-balf. 


Divida'tur in partes sequales 


. D. in p. seq. 


Let it be divided into equal parts. 


Div'ide. 


D., Div. 


Divide (thou). 


Dividen'dus. 


Dividend. 


To be divided. 


Do'sis. 


Dos. 


A dose. 


Extend'de supra. 


Exten. sup. 


Spread upon. 


Fac, fiat, fiant. 


F. 


Make, let be made, let them be 
made. 


Fil'trum, Filtra. 


Ml. 


A filter. Filter (thou). 


Gargaris'rna. 


Garg. 


A gargle. 


Grammum, Gramma. 


Gm. 


A gram, grams. 


Gutta, Guttse. 


Gtt. 


A drop, drops. 


Gutta'tirn. 


Guttat. 


Drop by drop. 


Haus'tus. 


Haust. 


A draught. 


Hora. 


H., Hor. 


An hour. 


In dies. 


Ind. 


Daily. 


Lage'na (lajena). 




A flask or bottle. 


Libra. 


lb. 


A pound, a Troy pound. 


Lo'tio flosheo). 




A lotion. 


Mag'nus. 


Mag. 


Large. 


Mane primo. 


Mane pr. 


Very early in the morning. 


Mas'sa. 


Mass. 


A pill-mass. 


Mica pa'nis ^inika). 


Mic. pan. 


A crumb of bread. 


Misce. 


M. 


Mix. 


Mistu'ra. 


Mist. 


A mixture. 



62 



GENERAL THERAPEUTICAL CONSIDERATIONS. 



Latin Word. 


Abbreviation. 


Translation. 


Nox, Nocte maneque. 




Night, at night and in the morn- 
ing. 


Numerus, Numero. 


No. 


A number, in number. 


Octarius. 


0. 


A pint. 


Pars. 


Par. 


A part (governs genitive). 


Partes sequales. 


P. se. 


Equal parts. 


Parvus. 


Parv. 


Small. 


Pediluvium. 




A foot-bath. 


Pencillium camelinum. 


Pencil, cam. 


A camels' -hair pencil or brush. 


Per fistulani vit-ream. 




Through a glass tube. 


Phiala. 


Phil. 


A vial. 


Pro re nata. 


P. r. n. 


According to circumstances, occa- 
sionally. 


Quantum sufficiat. 


Q. s. (followed by gen- 
itive). 


As much as is necessary. 


Quaqua bora. 


Q. h. 


Every hour. 


Saturatus. 


Sat. 


Saturated. 


Scatula. 


Scat. 


A box. 


Secuucia. 


Secunc. 


An ounce and a half. 


Seinidrachma. 


Semidr. 


A hall-drachm. 


Semissis. 


Ss. 


A half. 


Signa. 


S., Sig. 


Sign. 


Sine. 




Without. 


Solutio. 


Sol. 


A solution. 


Solve, Solutus. 


Solv. 


Dissolve, dissolved. 


Spiritus. 


Spr. 


A spirit. 


Statiin. 


Stat. 


Immediately. 


Talis. 


Tal. 


Such, or like. 


Tere simul. 


Ter. sim. 


Eub together. 


Ter in die. 


T. i. d. 


Three times a day. 


Vehiculum. 


Vebic. 


A menstruum. 


Vitello ovi solutus. 


V. o. s. 


Dissolved in the yolk of an egg. 


Vitellus 


Vit. 


The yolk (of an egg). 



PART II. 

DRUGS. 

ACACIA. 

Acacia, U. S., Acacias Gummi, B. P., Gum Arabic or Gum Acacia, 
is a gummy exudate from the stems and branches of small trees 
known as Acacia Senegal, and other acacias growing in Northern 
Africa and in Australia. As sold in the stores it consists of round- 
ish tears of various sizes, or broken into angular fragments ; whitish 
or yellowish- white, translucent ; very brittle, with a glass-like, some- 
times iridescent fracture ; nearly inodorous ; taste insipid, mucilagin- 
ous ; insoluble in alcohol ; slowly and completely soluble in water, 
forming an odorless, mucilaginous liquid. 

Acacia is devoid of physiological action. 

Therapeutics. — Acacia is employed in medicine as a local applica- 
tion to inflamed and irritated mucous membranes, particularly of the 
upper air-passages, and also, when dissolved in water, in the form of a 
drink when the same conditions exist in the mucous membranes of 
the alimentary canal and genito-urinary tract. In all these states it 
is useful as a vehicle for more powerful remedies. Made into a mu- 
cilage with flaxseed, to which liquorice may be added, it is largely 
employed as a drink to loosen a hacking cough in children or in 
adults. The flaxseed should not be boiled, but allowed to stand on a 
moderately warm part of the " range," and the gum-arabic solution 
added with a little lemon-juice for flavoring purposes. Acacia is 
chiefly used in pharmacy for making pills, emulsions, and similar pre- 
parations, and is official in the form of the mucilage of acacia (3Iu- 
cilago Acacice, U. S. and B. P.) and the syrup of acacia (Syrupus 
Acacice, U. S.), the first containing 340 Gm. of acacia, lime-water 
330 gm. and water enough to make 1000 Gm., and the second 25 mils, 
of the mucilage to 75 mils, of simple syrup. 

Acacia is incompatible with 60 per cent, alcohol, subacetate of 
lead, ferric chloride, and borax. 

ACETANHJD. 

Acetanilidum, U. S. and B. P., is the monacetvl derivative 
[C 6 H 5 NH(CH 3 .CO)] of aniline. 

It occurs as colorless, shining, micaceous, crystalline laminse, or a 
crystalline powder; odorless, having a slightly burning taste, and per- 
manent in the air. It is soluble in 190 parts of water and in 3.4 parts 

(63) 



64 * DRUGS. 

of alcohol at 25° C. (77° F.); in 20 parts of boiling water and in 
0.6 part of boiling alcohol; also soluble in 17 parts of ether and 3.7 
parts of chloroform at 25° C. (77° F.). It is made by the action of 
glacial acetic acid upon aniline, forming acetanilid or phenyl-aceta- 
mide. The word antifebrin is a registered name, and its use should 
be avoided by the profession, since its employment obliges the druggist 
to use the acetanilid made by one firm instead of the drug made 
by other chemists who manufacture it as an ordinary chemical 
compound, and do not charge so high a price as do those who market 
the product under a registered name. 

Physiological Action. — Acetanilid has been studied experimentally 
and clinically to a very great extent, and fairly definite outlines 
of its action have been mapped out. 

Nervous System. — On the nervous system acetanilid has been 
found to act as a sedative, the sensory portion of the nerves and 
spinal cord particularly being quieted. After a poisonous dose gen- 
eral anesthesia comes on, with total loss of reflex action and with 
motor and sensory paralysis. The portions of the nervous system 
affected in these changes are, primarily, the sensory side of the 
spinal cord and the sensory nerves, the motor apparatus being least 
influenced. The muscles are only indirectly influenced by the poison. 

Circulation. — On the circulation acetanilid has but little direct 
influence except when used in poisonous doses. Applied to the frog's 
heart, it at first accelerates its beat and increases its force, but soon 
causes a weakening, ending with arrest in wide diastole. Upon the 
higher animals it causes, in toxic dose, an immediate fall of arterial 
pressure with a diminution in the size of the pulse-waves and all 
the evidences of cardiac and circulatory depression, notwithstanding 
the fact that death ensues from respiratory failure. The cause of 
this fall of blood-pressure is a direct depressing action on the heart 
associated with failure of the vasomotor system, as asphyxia causes 
no rise in pressure. 

In medicinal dose acetanilid causes no circulatory changes of 
moment in the healthy individual. Sometimes the pulse-rate is 
increased, sometimes diminished. The tendency is, however, toward 
depression rather than stimulation of the circulation. 

Blood. — When used in large doses, the action of this drug upon 
the blood is more pronounced than its influence upon any other part 
of the body, causing this tissue to become brownish red, decreasing 
its oxygen-carrying power, and, finally, reducing the hemoglobin to 
methsemoglobin to a very considerable extent. The question as to 
the influence of acetanilid upon the corpuscles is still undecided, 
some observers declaring that these bodies are disorganized, while 
others assert that they remain intact. In moderately large poison- 
ous doses it may not affect the corpuscles, but if its use in large 
amount be continued for some days, or a very large amount be used 
at one time, corpuscular destruction certainly occurs, free haemoglobin 



ACETANILID. 65 

appearing in the urine in its characteristic forms. The normal alka- 
linity of the blood is decreased, and the urine becomes dark and 
brownish in color, and the blood-crystals of Teichmann are found in 
it. In medicinal doses the blood shows no change except in cases 
where idiosyncrasy is present or the doses are unusually large. Under 
these circumstances the blood in the arterial system becomes darker 
than normal. 

Respiration. — No effect is produced upon this function by 
acetanilide when given in moderate doses. When poisonous doses are 
used, the breathing at once becomes rapid and labored. Large doses 
produce death by paralysis of the respiratory centres. These effects 
are primarily due to the alterations in the blood, which so influence 
oxygenation of the tissues as to spur the respiratory centre to greater 
effort, while at the same time it is beginning to be directly depressed 
by the drug itself, so that impairment of its function is soon manifest. 
Bokai asserts that the drug paralyzes the peripheral motor nerves, 
which, if true, brings forward a third factor in the respiratory failure. 

Temperature. — When given in full medicinal doses, acetanilid 
lowers the normal bodily temperature or else fails to produce any 
change. In poisonous doses it produces a decrease in temperature 
depending on the amount employed, and may cause collapse and rigors. 
On a fever temperature it acts as a powerful and fairly constant 
antipyretic, lowering the fever by decreasing heat -production and in- 
creasing heat-dissipation, heat-production being the function most 
affected. 1 Whether the decrease in heat-production is due to an ac- 
tion on the heat-centres in the nervous system, or upon other causes, 
is not known. Some investigators have claimed that the fall depends 
upon the partial reduction of the haemoglobin of the blood, whereby 
less oxygen is carried to the tissues and less combustion ensues. This 
seems doubtful in view of the fact that spectroscopic examination of 
the blood fails to show any such change from the use of medicinal 
doses. That the fall of temperature is not dependent on the sweat 
produced is proved . by the fact that the temperature falls even if 
enough atropine be given to stop all perspiration. 

Kidneys, Tissue- waste, and Urine. — Much contradictory evi- 
dence exists in regard to the changes which occur in these organs and 
their excretory products under the influence of acetanilid, but most 
observers agree that the excretion of urea is increased (Lepine, Chit- 
tenden and Taylor). Less uncertainty exists as to its influence on 
the elimination of uric acid, which is increased rather than dimin- 
ished by the drug. After excessively large doses the urine becomes 
dark from the presence of broken-down blood-coloring matter. 

Elimination. — The drug is eliminated by the kidneys as para- 
amido-phenol sulphate, and is entirely passed out of the body in about 
twenty-four hours. 

iThe author's reasons for holding to the opinions stated can be found in his Boylston 
Prize Essay of Harvard University, on Antipyretics. 
5 



66 DRUGS. 

Antiseptic Action. — Acetanilid possesses distinct antiseptic powers, 
but is not capable of acting as a disinfectant. (See Therapeutics.) 

Toxic Changes from Prolonged Use. — Although it has been asserted 
that no untoward effects result from the constant and prolonged use 
of acetanilid in large doses, there can be no doubt that this assertion 
is untrue. Used constantly in excess, congestion of the liver, 
kidneys, and spleen occurs, and if the dose be poisonous, clots may 
be found in the cardiac cavities. There may be also a progressive 
decrease in the number of the red blood corpuscles. On the other 
hand the popular idea that its fairly frequent use is deleterious is 
in the great majority of cases false. 

Poisoning. — In man this drug in toxic quantity causes the lips to 
become blue and the face livid, cyanosed, expressionless, or anxious. 
The forehead and cheeks become covered with sweat, which gradually 
extends over the rest of the body. The pulse is soft and compres- 
sible, but slow, and finally very weak. The respirations become slow 
and shallow. 

The treatment of a case of poisoning by acetanilid should consist 
in supporting measures, the use of stimulants, external heat, bella- 
donna to maintain blood-pressure, strychnine to aid the respiration, 
and oxygen inhalations if they are necessary to combat cyanosis. 

Therapeutics. — The employment of acetanilid in fevers must 
depend very much upon the condition of the patient and the char- 
acter of his disease. The mere existence of a high temperature is not, 
correctly speaking, an indication for any antipyretic remedy. The 
phase of the disease must be recognized, and the question as to 
whether the fever which is present is harmful must be duly weighed. 
(See Treatment of Fever, Part IV.) 

In typhoid fever, though the drug possesses decided antipyretic 
power, it often causes great depression and collapse, and in no way 
influences favorably the duration or general course of the disease. 

For the same reasons the use of acetanilid in phthisis is inadvis- 
able, for, although it greatly affects the hectic fever, it is very apt to 
cause collapse, profuse sweating, and depression. Thus the writer 
has repeatedly seen cases of phthisis in which the attempt to control 
the fever by this drug resulted in the symptoms just named; and 
Riese points out, what the author has also noted, namely, that in 
this disease cyanosis is very apt to come on after the use of the 
drug. 

In regard to the employment of acetanilid in sthenic fevers, it at 
once becomes evident that a drug absolutely unsuited to a case of 
asthenic disease may, on the other hand, agree with a sthenic-fever 
patient very well. In consequence of this, we find that the sweating 
produced by acetanilid is not so marked or troublesome in diseases 
of a dynamic type, and that, in consequence, it more rarely causes 
collapse; but even in this class of cases, and particularly in both 
varieties of pneumonia, the use of acetanilid is rarely advisable. 



ACETANILID. 67 

Indeed, the antipyretic use of this and similar compounds is yearly 
becoming less and less. 

In much the same manner that antipyrine was found, some time 
after its introduction, to be possessed of pain-relieving power, so 
acetanilid has been discovered to possess similar properties. Almost 
every form of nerve-pain seems to indicate its employment. It has 
been successfully used in the crises of ataxia, the severe dartings 
of neuralgia, in cases of sciatica, and severe headaches often yield 
to its influence. Experience has proved it to be of value in epilepsy. 

The employment of acetanilid in acute rheumatism may be sepa- 
rated, if desired, into that devoted to the relief of pain and the 
reduction of pyrexia. There can be no doubt whatever of the 
ability of the drug to control the fever of this disease, and the ques- 
tion as to whether it favorably influences the severity of the pain 
of the malady is to be answered strongly in the affirmative. It is 
not curative. (See Rheumatism, Part IV.) The dose for cases of 
rheumatism should be 4 (0.25) to 6 (0.4) grains three times a day. 
In subacute rheumatism of the muscular type, acetanilid will often 
give marked relief. 

Acetanilid in dry powder is of value in the treatment of chancroids, 
and in the antiseptic dressing of wounds when used alone or with 
equal parts of borax. 

In many cases of obstinate vomiting, particularly that following 
surgical operations when an anaesthetic has been used, acetanilid is a 
useful remedy. The drug is usually best given in the dose of 1 grain 
(0.06) every half-hour until 6 grains (0.4) have been taken; and the 
following prescription may be used in compressed tablet, pill, or 
powder, preferably the latter, in order to increase the sedative effect 
on the stomach and support the heart. 

1$ — Acetanilidi gr. vj (0.4). 

Caffeinse citratse gr. iij (0.2). 

Camphorae monobromatse gr- vj (0.4). — M. 

Fiant pilulse vel chartulae, No. vi. 
S. — Wash down with a little water or else dissolve powder in a drachm of brandy, 
pour over cracked ice, and give it slowly from a spoon. 

Acetanilid has been recommended as a local haemostatic in epis- 
taxis, and has been given internally with asserted advantage in 
hcemoptysis. 

Acetanilid distinctly increases the susceptibility of a patient to 
cold, and for this reason it should not be used for the relief of 
neuralgic or other pain before leaving the house in cold weather if 
it can be avoided. 

Incompatibility. — Acetanilid is decomposed by strong alkalies, and 
alkaline iodides and bromides in aqueous solution precipitate it. It 
forms a soft mass or liquid with hydrated chloral, with phenol, 
resorcinol, thymol, and antipyrine. 

Untoward effects are not common unless acetanilid be used with care. 



68 DRUGS. 

The writer has collected a number of cases (thirty-eight) in which 
unfavorable signs appeared after its use, but untoward action was 
never seen unless the dose given was excessive for the case which 
received it. The dose most commonly producing such symptoms 
was from 3 (0.2) to 10 grains (0.6). In only three instances of the 
series did death occur — one from heart-clot and two from excessive 
dosage. No deaths were reported from moderate amounts, although 
some of the cases were alarming. Very rarely symptoms of poison- 
ing by acetanilid such as are described on p. 66, follow its general 
use as a dusting-powder over wounds and other breaks in the skin. 

Administration. — Acetanilid may be given in doses varying from 
2 (0.12) to 10 grains (0.6), the last-named amount being usually 
excessive. As it is virtually insoluble in water, it should always be 
administered in wine or spirit, in which it is soluble, or in capsules 
or pills. The antipyretic effect is manifested about one hour after 
the drug is taken. When neuralgias are to be treated or similar 
forms of pain are present, one of the bromides, in the dose of 
10 grains (0.65), may be combined with acetanilid with advantage. 

This drug is not to be used if there is reason to believe that marked 
renal congestion or irritation is present. 

ACETIC ACID. 

Acidum Aceticum, U. S. and B. P., is a clear liquid, composed of 
not less than 36 per cent, nor more than 37 per cent, of glacial acetic 
acid, having a strong, characteristic, vinegar-like odor, a sharply acid 
taste, and a strongly acid reaction. Miscible with water or alcohol 
in all proportions. It is obtained from wood by destructive distilla- 
tion, or by the oxidation of ethyl alcohol. 

Acetum, or Vinegar, is practically dilute acetic acid. 

Therapeutics. — Acetic acid is seldom used internally. The glacial 
or absolute acetic acid (Acidum Aceticum Glaciate, U. S. and B. P.) 
is used as a powerful escharotic. It may be applied to warts and 
other growths, and to old sores where the granulations are profuse 
and healing is slow. The dilute acid (Acidum Aceticum Dilutum, XL 
S. and B. P.) is used as a lotion in night-sweats and to arrest epistaxis 
and other minor hemorrhages. When employed as a lotion it should 
be diluted one-half with water. Vinegar, or dilute acetic acid, has 
been used internally to decrease obesity, but is a harmful and useless 
remedy, disordering digestion and reducing the patient's strength. 

Inhalation of vinegar fumes from a cloth saturated with this liquid 
sometimes will control vomiting after the use of an anaesthetic. 

In the following mixture acetic acid may be used for the removal 
of vegetations about the external genitals : 

I$— Acidi salicylici gr. xxx (2.0). 

Acidiacetici f §j (30.0).— M. 

S. — Apply with a camel's-hair brush. 

Only slight pain is caused by this application. 



ACETPHENETIDIN. 69 

Poisoning. — When overdoses of acetic acid are taken, the treat- 
ment consists in the use of large draughts of milk, alkaline liquids, 
such as lime-water, soap-water, etc., and the general measures suit- 
able for the treatment of gastro-enteritis. (See Gastro-enteritis, Part 

IV.) 

Contraindications. — Nursing mothers should not take freely of 
vinegar, as it may produce a troublesome diarrhoea in the nursling. 

ACETPHENETIDIN (PHENACETIN) . 

Phenacetin (Acetphenetidinum, U. S.; Phenacetinum, B. P.) is a 
coal-tar product introduced several years ago as an antipyretic of the 
same character as antipyrine. It occurs in white, glistening, crystal- 
line scales without odor or taste. It is only slightly soluble in water. 
Acetanilide and antipyrine are sometimes substituted for phenacetin. 
iPure phenacetin when shaken with nitric acid is colored yellow, which 
color persists when it is heated- This is not the case with the other 
products named. 

When this drug is carelessly made, an impure product is the result, 
which produces irritation of the kidneys, and, in consequence, causes 
grave complications. Reuter states that the impurity may be dis- 
covered by placing a small amount of chloral hydrate in a test-tube, 
melting it at a temperature just sufficient to liquefy it, and then add- 
ing the suspected sample of phenacetin in the proportion of one-fifth. 
If the phenacetin is impure, it will become purple, then red, and 
finally blue. 

Physiological Action. — Unfortunately, our knowledge of the physio- 
logical action of phenacetin upon the nervous system is not so thor- 
ough as is desirable. We know, however, that it is a distinct nerv- 
ous sedative, and that it acts particularly on the spinal cord in its 
sensory tracts. 

Upon the circulation the drug has little or no effect unless given 
in doses exceeding those generally employed, or continued in overdose 
for some time. The blood after the ingestion of these doses becomes 
dark and blackish from the formation of methsemoglobin, and the 
urine becomes dark yellow and reacts with Fehling's solution. Upon 
normal bodily heat and the heat of fever the drug exerts a depressing 
effect, decreasing the production and increasing the dissipation of heat. 

Therapeutics. — Our knowledge concerning the influence of phen- 
acetin upon the human body in disease may be divided into two 
separate parts in much the same manner that we divide the uses of 
antipyrine — namely, its uses as an antipyretic and as an analgesic. 

The remarks made in the article on Fever (Part IV.) clearly show 
why phenacetin should not be used as an antipyretic, for every drug 
used as an antipyretic is, as a rule, deleterious. It is far better to re- 
duce the fever with cold applications. (See Cold in Fevers, Part III.) 

Upon the nervous system phenacetin acts as an antineuralgic, and 



70 DRUGS. 

is of service in migraine and ordinary headache from eye-strain, in 
the pains of tabes dorsalis, in intercostal neuralgia, and in rheumatism. 
Sometimes it relieves these troubles when antipyrine fails. Altogether 
we may consider phenacetin a rival of antipyrine in the power to 
relieve pain. 

For neuralgia the folio whig prescription may be ordered : 

R — Acetphenetidini gr. x (0.60). 

Caffeinse citratae gr. v (0.30). 

Strontii bromidi gr. xx (1.3.). — M. 

Pone in capsulas, No. v. 

S. — One or two capsules every hour while the pain lasts. 

In subacute rheumatism and in the lumbar or muscular pains of 
influenza a powder or pill of 4 grains (0.25) of phenacetin and 5 
grains (0.30) of salol, given three or four times a day, is most efficient. 

Under the name " Lactophenin" & nearly related compound of 
phenacetin is sometimes used for the same purposes. In phenacetin 
one atom of hydrogen is replaced by an acetic-acid radicle ; in lacto- 
phenin this atom of hydrogen is replaced by a lactic-acid radicle. 
Similarly "citrophen" is made by replacing the atom of hydrogen by 
a citric-acid radicle. It is also used as a substitute for phenacetin. 

The dose of these drugs is about the same as that of phenacetin, 
or a little larger, about 5 to 10 grains (0.30-0.60) three times a day. 



ACOINE. 

Acoine is a synthetic substance introduced into ophthalmic surgery 
as a local anaesthetic and antiseptic. It is used in a 1 or 2 per cent, 
solution. 

ACONITE, OR MONKSHOOD. 

The aconite of the U. S. and B. P. is the dried tuberous root of 
Aconituni Napellus Linne (Fam. Ranunadaceoz) , collected in autumn; 
yielding, when assayed by the process given in the U. S. P., not less 
than 0.5 per cent, of ether-soluble alkaloids of Aconite. 

Aconite is indigenous in Germany, France, and Switzerland, and 
is cultivated as a garden-plant in Europe and America. The root 
resembles so strikingly that of horseradish as to be readily confused 
with that condiment, but does not emit the pungent fumes of the 
latter when it is scraped or broken. It is also to be remembered that 
aconite produces a sensation of heat in the mouth when chewed. 
The active principle upon which the therapeutical value of aconite 
would appear to depend is aconitine, but there is reasonable doubt 
whether this can be relied upon as completely as the preparations of 
the crude drug; the aconitine of commerce, moreover, varies very 
much in strength, because some of it is amorphous and impure, while 
other samples are pure and crystalline. Further than this, even the 
crystalline form is exceedingly variable in strength. In addition to 



ACONITE, OR MONKSHOOD. 



71 



Fig. 5. 




aconitine, Dunstan asserts that there are two amorphous alkaloids — 
namely, benzaconine and aconine. Aconitine is 200 times as toxic as 
benzaconine and 2000 times as toxic as aconine. 

Physiological Action. — When aconite is placed on the tongue it 
produces a sensation of tingling and burning which extends over the 
pharyngeal surface, and into the stom- 
ach if the drug is swallowed. This 
is due to its primary irritant and second- 
ary benumbing action on the sensory 
nerve-endings of the mucous membrane. 
It sometimes causes a sensation of con- 
striction in the fauces. 

Nervous System. — In full medici- 
nal dose aconite depresses the functional 
activity of the perceptive centres in the 
brain, and the sensory side of the spinal 
cord, but chiefly depresses the periphe- 
ral ends of the sensory nerves. Applied 
to a mucous membrane, it acts as a 
local anaesthetic, but is too irritating for 
this use in the eye. On the motor por- 
tion of the body it exerts little inflll- a, vagus centre stimulated by acon- 

ence unless given in poisonous doses, ite, which slows pulse ;.B,heart-mus- 

i ., , ,i. r> cle depressed, which slows pulse ; c, 

when it paralyzes the motor tract of vasomotor cen tre depressed, which 

the Spinal COrd and the peripheral motor lowers arterial tension ; d, respira- 
IierveS tory centre depressed. 

Circulatory System. — When aconite is given in moderate medi- 
cinal dose it exercises no marked effect on any part of the organism 
save the circulation, which becomes somewhat slower from stimula- 
tion of the vagus centres and by the drug acting as a sedative to the 
heart-muscle itself. That cardiac slowing is caused has been denied 
by Price, but my experience is that it does occur. The arterial pressure 
is slightly decreased by these doses, chiefly by the decrease in cardiac 
force. If large doses are used, the pulse becomes still more feeble and 
slow, and the arterial pressure falls from depression of the vasomotor 
centre. When a poisonous dose is given, it causes first a marked fall 
in pulse-rate and arterial pressure, preceded sometimes by a quicken- 
ing due to a condition of weakness and abortive cardiac action : this 
condition gradually passes into diastolic arrest of the heart, the viscus 
becoming paralyzed and refusing to respond to stimuli. 

Respiration. — In moderate doses aconite quiets the respiratory 
movements slightly, particularly if the breathing is hurried. In poi- 
sonous doses it paralyzes the respiratory centre, and so causes death. 

Temperature. — Aconite acts as a distinct reducer of fever, proba- 
bly because of increased heat-radiation arising from relaxation of the 
capillaries and impaired circulation. 

Absorption and Elimination. — Aconite is rapidly absorbed and 



72 DRUGS. 

destroyed by oxidation, so that its effects do not last for any length of 
time. The effect of aconite when given in a large medicinal dose lasts 
for about three hours. It usually increases the urinary flow. 

Poisoning. — When aconite is taken internally in excessive amount, 
it causes tingling of the mucous membranes wherever it touches them, 
which sensation finally amounts to severe burning. This soon passes 
away, and is followed by a sense of tingling about the lips and finger- 
tips or all over the skin. At the same time the patient feels relaxed ; 
the pulse at first becomes weak and slow, but later may be rapid aud 
running, so that it seems a mere trickle under the finger ; sweating is 
more or less marked, and fainting may ensue. . Vomiting may occur, 
bat is rare. The respirations now become slow and shallow, seeming 
to expand the lung to the smallest possible extent consistent with life. 
The face is pallid and anxious. Consciousness is preserved unless lost 
through an attack of syncope. There may be exophthalmos, or the 
eyes may be sunken and dull. The sclerotic is pale and pearly-look- 
ing. There is excessive pallor of the face. Clonic convulsions of 
unknown origin sometimes occur. There may be marked anaesthesia 
of the skin. The pupils may be normal, contracted, or dilated 
widely. The temperature of the body is sub-normal. Death may 
be gradual or sudden, the slightest movement of the body which 
throws any strain on the heart stopping that organ in diastole 

Treatment of Poisoning. — The patient is to be placed in a prone 
position on a bed or board, with the feet higher than the head, in order 
to confine the circulation as far as possible to the vital centres at the 
base of the brain. Hot bottles or bricks are to be placed about the 
body for the purpose of maintaining the bodily heat. Emetics are 
not to be given if the symptoms are severe, as vomiting may cause 
cardiac failure, owing to the muscular effort involved, or the stomach 
may be so depressed that emetics will not act. If vomiting comes 
on, the vomitus should be received into a towel, the patient not being 
allowed to raise his head. The stomach is to be washed out by 
means of a stomach-pump or a siphon of rubber tubing. Ether may 
be given hypodermically, Hoffman's Anodyne by the mouth, and this 
followed by digitalis. Full hypodermic doses of strychnine, such as -^ 
to ro (0.003-0.006) grain, should be given to stimulate the respira- 
tion and heart. The ether acts at once, and stimulates until the 
digitalis, which is the physiological antagonist of aconite, but slow 
and more prolonged in its effects, asserts itself. Atropine, because 
of its stimulating effect on the vasomotor system, may also be used. 
If the breathing fails, artificial respiration is to be employed, or if 
the heart seems about to cease its action, a whiff of nitrite of amyl 
may start it going again; but only a few drops of the nitrite should 
be used, as large amounts depress this organ. 

Untoward Effects. — Aconite when applied locally or taken internally 
may cause in susceptible persons a vesicular, or even a pustular, 
eruption, or instead an intense itching of the skin may be developed. 



ACONITE, OR MONKSHOOD. 73 

Therapeutics. — Aconite is used chiefly for its influence as a cardiac 
and circulatory sedative, for its effects on the peripheral sensory 
nervous system, as in the vomiting of pregnancy, and in those states 
in which, through inflammation elsewhere, the nervous system needs 
a sedative which will simultaneously reduce arterial tension. In the 
early stages of all acute inflammations aconite may be of service. 
Aconitine may be applied locally over superficial nerves in neuralgia 
in the form of an ointment (2 grains [0.12] to 1 drachm [4.0], or as 
the oleate of aconitine, 2 grains [0.12] of the oleate to 100 [6.6] of 
sweet oil). In the earlier stages of gonorrhoea aconite in small 
doses frequently repeated is a valuable remedy, and later in the 
disease tends to prevent chordee by its influence on the nervous 
centres. It is useful in croup, quinsy, sore throat, severe colds, bron- 
chitis, and asthma due to exposure, in their early stages. When sup- 
pression of menstruation follows exposure to cold, this drug given with 
a hot drink and a hot sitz-bath, will often restore the Aoav. In peri- 
carditis it is valuable to allay the inflammation and quiet the excited 
heart. Aconite is by far the best circulatory and nervous sedative for 
children in the earliest stages of the sthenic fevers, particularly of the 
irritative type. 

J& — Tincturae aconiti Tilviij (0.5). 

Spiritus aetheris nitrosi f^ij (8.0). 

Liquoris potassii citratis q. s. ad f'Jij (60.0). 

S. — Teaspoonful (4 mils.) in water every hour or two for a child of five years. 

Aconite ought not to be used in adynamic, asthenic affections. It 
is harmful in prolonged acute diseases, such as scarlet fever, if con- 
stantly employed. 

In persons who suffer from asthma which is preceded by coryza, 
aconite does good if given in the earliest stages. 

In nervous palpitation of the heart and in the palpitation of exces- 
sive cardiac hypertrophy aconite is valuable. In many cases of this 
character, where there is not only hypertrophy but also impaired in- 
nervation, the use of a prescription containing aconite and digitalis 
proves of service, for the minute doses of digitalis stimulate the 
vagus nerves, and the aconite not only steadies the heart by its stim- 
ulant effect on the vagus, but also counteracts the stimulant effect of 
the digitalis on the heart-muscle : 

I$— Tincturae aconiti rrjxlv (8.0). 

Tincturae digitalis. . , f5ij(3.0). 

Tincturae belladonnae foliorum f 3iss (6.0) 

Tincturae gentianae compositae . . . q. s. ad f §iij (90.0).— M. 

S. — Teaspoonful every six hours. 

In the epistaxis of full-blooded people aconite often affords great relief. 

Full doses of DuquesnePs crystalline aconitine are of value in some 
cases of obstinate neuralgia. This crystalline salt is about four times 
stronger than the amorphous variety. 



74 DRUGS. 

Administration. — As a general rule, small divided doses of the drug 
in the form of the tincture, 2 to 4 minims (0.1-0.2) given every 
fifteen minutes, will act better than a full dose given at once, unless 
the condition of the patient requires very active treatment. 

Preparations. — Tinctura Aconiti, U. S., should contain 0.045 Gm. 
to 0.055 Gm. of ether-soluble alkaloids in each 100 mils., and used in 
the dose of 3 to 20 minims (0.20-1.30). The tincture of the U. S. P. 
of 1910 is only 10 per cent, strength instead of 35 per cent, in former 
days. The dose of the B. P. tincture is 2-5 minims (0.12-0.3). A 
very useful way of employing it is in the form of tablet triturates. 
The extract of aconite (Extraction Aconiti, U. S.) is given in the dose 
of i to f grain (0.015-0.045). The fluidextract (Fluidextr actum 
Aconiti, U. S.) is given in the dose of 1 to 2 minims (0.06-0.12). 
Fluidextract of aconite should contain about 0.50 Gm. of alkaloids in 
each 100 mils. Fleming's tincture ought never to be used. The 
dose of the active principle aconitine (Aconitina, U. S. and B. P.) is 
tJtt to 2^0 & ram (0.00015-0.0003), but it ought never to be used 
internally. The B. P. preparations that are not official in the U. S. P. 
are aconitine ointment ( Unguentwn Aconitinoe) and aconite liniment 
(Linimentum Aconiti). 

ADALIN. 

Adalin, bromdiethylacetylcarbamide, is an odorless, almost color- 
less white powder, readily soluble in alcohol, but not in water. It is 
an efficient mental and nervous sedative closely resembling the ordi- 
nary bromides in power, and is a useful drug in cases of mild insomnia 
and nervous irritability. Taken for any length of time it sometimes 
causes skin lesions like the older bromides. The dose is 5 to 20 
grains (0.3-1.3) generally given in tablet form. 

ADONIS VERNALIS. 

From Adonis vernalis, a plant indigenous in Europe and Asia, is 
derived a glucoside, Adonidin. When given to one of the mammalia 
— the dog, for instance — it causes an increase in heart-force and a 
rise of arterial pressure. In the frog poisonous amounts arrest the 
heart in diastole. 

The indications for the use of adonidin are all conditions of car- 
diac failure, particularly the presence of cardiac dropsy. It is much 
inferior to digitalis and caffeine, but may be employed when these 
fail, as it sometimes succeeds under such circumstances. Within the 
last few years adonis vernalis and the bromides have been combined in 
the treatment of epilepsy with asserted success. 

The dose of adonidin is J to ^ grain (0.008-0.015), three times a 
day ; or 4 to 8 parts of the plant — all portions of which are employed 
— may be added to 180 parts of water, and of this infusion a half- 
ounce (16.0) may be given every four hours. 



ALCOHOL. 75 



AGAR. 



Agar, U. S., 'is a gelatinous substance obtained in Japan from 
several species of seaweed that grow on its coast. It is identical with 
the agar-agar used in the bacteriological laboratory and is used in 
medicine as a remedy for constipation. It possesses no physiological 
activity, so far as the general economy is concerned, and it does not 
exercise any true medicinal effect upon the intestine. By absorbing 
moisture it becomes swollen and soft and, by adding to the bulk of 
the intestinal contents, indirectly acts as a laxative in much the 
same type of cases as that in which mineral oil now is used. While 
it is of the nature of a carbohydrate, Mendel and others have shown 
that it is not attacked by the digestive ferments or the intestinal 
bacteria. Probably its greatest sphere of usefulness is in those cases 
of constipation in which the stools are unduly dry. Agar appears 
as a coarse granular powder and is given in the dose of from one to 
two heaping teaspoonfuls, or even one or two tablespoonfuls once 
or twice a day, eaten dry or mixed with some cereal or breakfast 
food. It can also be used in bread and biscuits. 

AGAEICIN. 

Agaric, or Touchwood, or Punk, has been used in the Southern 
United States very largely in the dose of 5 grains (0.3) every few 
hours in the treatment of the night-sweats of phthisis ; and agaricin, 
the alcoholic extract of the drug, has been used with extraordinary 
results, under these circumstances, by certain German and English 
physicians, in the dose of from 1 to 2 grains (0.06-0.12) in capsule 
every five hours. Its physiological action is unknown, but it is sup- 
posed to act upon the nerve filaments in the sweat-glands. The 
writer has employed it frequently in varying dose, and has never seen 
any decrease whatever produced by it in the sweats of phthisis, al- 
though he has watched its action most closely. Sometimes agaricin 
causes nausea and diarrhoea. 

ALCOHOL. 

Ethyl Alcohol (Alcohol EthyUcum) is the only alcohol used in medi- 
cine. Some of the other alcohols are exceedingly poisonous. Amylic 
alcohol is fusel oil. 

Alcohol is a liquid resulting from the fermentation of starches or 
sugars in the presence of heat. It is official in three forms — as 
Alcohol, U. S., containing 92.3 per cent, by weight of the spirit and 7.7 
percent, of water; Alcohol Dehydratum, U. S., and Alcohol Absolutum, 
B. P., with not more than 1 per cent, by weight of water; and Alcohol 
Dilutnm, U. S., or dilute alcohol, 41.5 per cent, by weight of spirit 
and the remainder water. The drug is generally given in the form 
of whisky or brandy, and when the word alcohol is used in the say- 



76 DRUGS. 

ing, "Give the patient alcohol," one of these two liquids is always 
meant unless it is otherwise stated. 

Notwithstanding the almost universal use of alcohol as a stimulant 
by the laity and the medical profession, it cannot be denied that evi- 
dence of scientific character and weight is constantly being brought 
forward which shows that its dominant action is depressant upon all 
parts of the body. It is claimed that under its influence the total 
amount of work accomplished in a given space of time is less than 
when it is not taken, and that the quickening of the pulse under its 
influence is not an evidence of strength. Nevertheless clinical 
experience, too great to be ignored, stands for the continued employ- 
ment of the drug. The drug does not act as a stimulant in the ordi- 
nary sense of the term, but nevertheless readjusts the circulation by 
dilating the peripheral vessels and influences the protective powers 
of the body by affecting the blood-cells or the blood-serum or the 
lymph. This belief seems to find support by reason of experiments 
carried out by the author, in which he was able to show that alcohol 
produces a distinct increase in the bacteriolytic power of the blood 
in disease, probably by increasing the activity of the complemental 
body. These facts explain the good results which follow the use of 
the drug in clinical medicine. (See below.) 

Physiological Action. — Nervous System. — Alcohol never acts as a 
true stimulant to the brain, the spinal cord, or the nerves. On the 
contrary, its dominant influence is depressant. The increased activity 
of thought and speech after its use is not due to stimulation, but to 
depression of the inhibitory nervous apparatus. The activity is there- 
fore that caused by lack of control, and is not a real increase in 
energy. So far as the brain is concerned, it does not increase the 
vigor of thought nor its depth, nor does it enable a man to work out 
a problem which is difficult. On the contrary, it rather benumbs the 
activity of mental processes and acts as a nervous sedative which is 
often advantageous. The effect of moderate doses differs from the 
effect of large ones in degree, but not in kind. Reflex action may be 
increased by the same depression of inhibition, but not by reason 
of any true stimulation of the cord. In large doses it produces lack 
of coordination by depression of the brain and lower nervous' system, 
the loss of coordination being due largely to impairment of sensation, 
so that the sense of touch and the muscle sense are interfered with. 
This effect makes a drunken man fail to recognize the angles or uneven 
surface of surrounding objects, and the impaired mental power and 
disordered judgment, combined with the imperfectly acting motor and 
sensory pathways, cause him to stumble and fall. 

Circulatory System. — Careful scientific research has proved that 
alcohol is in no sense a true stimulant to the circulation in healthy 
persons. Given in such a dilute form so that it cannot act as a local 
irritant to the stomach, it produces no change in pulse-rate or pulse- 
force. If the dose is large enough to cause any appreciable change 



ALCOHOL. 77 

in the activity of the circulation, it is in the nature of depression rather 
than stimulation. This is true in the laboratory and at the bedside. 
Alcohol does, however, produce very marked alterations in the distri- 
bution of the blood, as is seen in the flushing of the capillaries of 
the skin after its moderate use. In other words, it does not affect all 
the bloodvessels in a similar manner, for while the cutaneous vessels 
are dilated, those of the muscles are contracted, as are also those of 
the splanchnic area. The beneficial action following the use of 
alcohol in disease when it is thought to act as a stimulant prob- 
ably depends upon the improved distribution of blood it pro- 
duces, just as the use of the sponge bath or cold plunge in typhoid 
fever readjusts the circulation and restores vascular tone. Little if 
any effect is exercised by alcohol upon arterial pressure when given 
in medicinal dose. In very large toxic doses alcohol depresses and 
finally paralyzes the heart and vasomotor system. 

Respiration — Respiration is not materially affected by alcohol. 

Temperature. — Alcohol never increases the number of heat units 
in the body, for though in its oxidation more heat is made than when 
no alcohol is used, the increased radiation, or loss of heat, from the 
skin and lungs under its influence more than counterbalances the gain 
caused by the drug. 

By its irritating effect on the mucous membrane of the mouth and 
stomach it produces a sensation of warmth, and warms the extremi- 
ties at the expense of the body by increasing the circulation of blood 
in those parts. This increase in the peripheral circulation is due to 
an increase in the rapidity of the flow of blood and to dilatation of 
the peripheral capillaries. If it be used to excess, the temperature 
rapidly falls, owing to the increase of heat-radiation produced by the 
free distribution of blood, as has just been described, and secondarily 
by the depression of the vital forces, for in overdose alcohol always 
acts as a depressant. 

Bodily Metabolism. — The quantity of carbonic acid given off by 
the body under the use of alcohol is not materially altered. Some 
observers have noted an increase, some a decrease, and some no change 
at all when alcohol is taken. These results have probably depended 
upon the work required at the time the alcohol is in the body, for the 
influences of exercise and rest are potent factors in determining the 
activity of combustion or oxidation processes in the economy. The 
use of moderate doses of alcohol by a healthy man at first increases 
the loss of nitrogen, but after two or three days this effect passes off 
aud there is a decrease in nitrogenous loss, the oxidation of the alco- 
hol saving the tissues. Atwater and Benedict have shown that, owing 
to the ability of the body to oxidize alcohol, this liquid substitutes 
itself for the oxidation of fats and so saves tissue waste. The gen- 
eral effect of alcohol is, therefore, to conserve the body fat and the 
body proteids as well. That is to say, alcohol, by being burned up 
in the body, yields energy and saves tissues which would otherwise be 



78 DRUGS. 

oxidized if no alcohol were taken. To express it in still another way : 
alcohol, by its oxidation, adds force, not tissue, to the body, but by 
protecting the fats and proteids of the tissues from oxidation, it may 
cause an increase in weight if it is properly utilized by the body. 

This book is not the place for a discussion of the sociological aspects 
of the use of alcohol, but enough will be found in these pages to indi- 
cate that alcohol taken in youth, when nutritional processes are 
unimpaired, is usually harmful. Alcohol taken by those who are 
devitalized by old age or by disease is advantageous. Youth needs 
no artificial food or nervous sedative. Old age and the man weakened 
by illness often needs something which is easily utilized for energy to 
support the system and make life easier. 

Elimination. — Alcohol is rapidly absorbed and rapidly destroyed 
by, or eliminated from, the body. In medicinal doses it is largely 
" burnt up;" but when taken in excess of the body's oxidizing power 
it is eliminated as alcohol by the lungs and by the skin, kidneys, and 
intestines. 

Digestion. — Alcohol added in any amount to food in a test-tube 
containing digestive ferments retards or inhibits digestion, but in the 
stomach, on the other hand, when used in moderation, it assists the 
process; for by reason of its irritant and stimulating properties it 
induces the secretion of the digestive juice. This statement has 
been proved correct by Kast, who gave alcohol to a human being 
with gastric fistula. Further than this, the presence of alcohol in 
moderate amount in the stomach aids absorption by stimulating the 
mucous membrane. When excessive amounts are ingested it disorders 
digestion by inhibiting the action of the digestive ferments. 

Therapeutics. — The chief use of alcohol is as a rapidly acting 
equalizer of the circulation in all forms of circulatory failure with 
feebleness due to low fevers and prolonged wasting diseases, in old 
age, and in convalescence from acute disease. In both croupous and 
catarrhal pneumonia, when these affections occur in alcoholics (see 
Pneumonia, Part IV.), alcohol is useful. In pneumonia, in one accus- 
tomed to its free use, it is often essential. 

Some additional conditions, to state them specifically, in which 
alcohol is indicated are fainting, sepsis and excessive wasting due to 
prolonged suppuration. It is also useful in many uses of sepsis 
combined with quinine and iron. 

Alcohol should never be given in the presence of circulatory excite- 
ment, but whenever the circulation fails during the progress of a 
chronic disease it is useful. In the catarrhal pneumonia of children, 
brandy or whisky is very useful in the dose of 5 to 60 minims (0.3-4.0) 
every two hours in a little water or milk when the circulation seems 
feeble. (See Administration.) In exhausting fevers, such as typhoid 
or typhus, alcohol finds its true usefulness. While it may be needful 
to give alcohol in some cases of enteric fever from the beginning to 
the end of the attack, for the double purpose of aiding digestion and 



ALCOHOL. 79 

of supporting the system, its administration should not be a mere 
matter of routine, but should be based upon clear ideas of the indi- 
cations it is calculated to fulfil. If the pulse is weak and the patient 
seems to be sinking, or the appetite is failing and adynamia is a press- 
ing symptom, alcohol is indicated; but if the pulse is good, and the 
passage of the patient through his illness is not a stormy one, alcohol 
should be excluded from the sick-room. Sometimes ordinary whisky 
or brandy will in severe typhoid fever disorder the stomach. The 
physician should then employ an old brandy or wine which has 
acquired by age an aroma which is called a "bouquet" 

In persistent vomiting the use of small doses of good brandy poured 
on cracked ice will often do much good. 

Alcohol is not only of service internally, but is also useful exter- 
nally as a wash or evaporating lotion over bruises, inflamed joints and 
wounds of a contused character. It acts as a cooling and antiseptic 
dressing. When used for its influence as a local antiseptic it acts 
best in the strength of 60 to 70 per cent, by volume, as the presence 
of the 30 or 40 per cent, of water, by softening the bacterial envelope, 
enables the alcohol to destroy the germ. Pure alcohol is there- 
fore much less serviceable than the dilute form. Alcohol is also 
useful for washing the skin of invalids, and "salt and whisky" 
applied by rubbing is an excellent mixture to stimulate the skin of 
unhealthy persons. 

Acute Poisoning. — In acute poisoning a tablespoonful of vinegar will 
often produce remarkable effects in restoring consciousness. How it 
acts is not known. In advanced poisoning by alcohol, with coma and 
total relaxation, external heat and hypodermic injections of digitalis 
and strychnine are indicated if the heart or respiration seems to be 
failing. Atropine should be administered to stimulate the vaso- 
motor system if the skin is relaxed and clammy, and counterirritation 
to the back of the neck is to be employed if any brain symptoms are 
present. The after-treatment consists in the use of substances stimu- 
lating to the stomach, such as ammonia, spirit of Mindererus, and 
spices, unless there is gastric inflammation, when emollient substances 
should be used to quiet the irritation. If persistent vomiting comes 
on, it must be quieted by the patient swallowing pieces of ice, or by 
minute doses of ipecac. Counterirritation should be applied over 
the belly. If the emunctories are not acting freely, thorough purga- 
tion by jalap or elaterium (40 grains [2.6] of jalap powder or | grain 
[0.008] of elaterium) should be employed; or full doses of calomel 
followed by a saline may be given if milder effects are sought. For 
the morning vomiting of drunkards Fowler's solution of arsenic is 
often a valuable remedy. 

In view of the frequency with which alcoholic and opium poisoning 
are confused, the following table is appended, which will be found of 
value in making a differential diagnosis as to the condition of the 
patient. 



80 DRUGS. 

Alcoholism and Opium Poisoning. 

Alcoholism. Opium Poisoning. 

1. Pupils normal or dilated. 1. Pupils contracted. 

2. Respiration nearly normal. Pulse 2. Respiration and pulse slow and 
rapid, and finally feeble. full. 

3. Face may be pallid. 3. Face suffused and cyanosed. 

4. Skin cool, perhaps moist. 4. Skin warmer than in alcoholic 

poisoning. 

5. Pulse rapid, at first strong, then 5. Pulse slow, strong, and full till 
weak. late * 



in poisoning. 



There is scarcely any difference as to consciousness in the two conditions. 
In medico-legal cases the urine should be preserved in hermetically sealed 
vessels for examination. 

Acute alcoholism and apoplexy are often confused. They are 
differentiated in the following table : 

Acute Alcoholism and Apoplexy. 

Alcoholism. Apoplexy. 

1. Pulse rapid, compressible, and 1. Pulse apt to be strong and slow, 
weak. 2. Skin hot or dry. 

2. Skin moist, or relaxed and cool. 3. Bodily temperature raised. 

3. Bodily temperature lowered. 4. Pupils unequal. 

4. Pupils equally contracted or dila- 
ted; generally dilated. 

5. No hemiplegia. 5. Hemiplegia : one side moved, the 

6. Breathing not so stertorous nor so other remaining motionless, 
one-sided in lips. 6. Respiration stertorous, the lips 

7. No facial palsy. being inflated on one side on expiration. 

8. Unconsciousness may not be com- 7. Facial palsy. 

plete. 8. Unconsciousness complete. 

The odor of alcohol in the breath is no guide, as acute alcoholism may have 
caused the rupture of a cerebral bloodvessel. 

The lethal dose of whisky is not determined. A few ounces may 
kill a child, whereas it is not uncommon for Polish laborers in this 
country to take as much as 2 or 3 quarts of whisky in a day without 
producing a condition approaching death. 

Chronic Poisoning of the Alcoholic Habit. — Chronic poisoning by 
alcohol results in very characteristic changes in the tissues. As the 
liver receives the alcohol from the stomach diluted only by the portal 
blood, it is often affected very early, and cirrhosis of this organ comes 
on with its accompanying gastric and nutritional symptoms. Mental 
disturbances are common, and neuritis may develop and produce 
paralysis or symptoms resembling locomotor ataxia. 1 

Chronic alcoholics can take large amounts of alcohol without much 
immediate effect because of the fact that they develop an ability to 
oxidize the drug which is not possessed by the ordinary individual. 

The treatment of chronic alcoholic poisoning may be carried out in 
two ways : First, by the isolation of the patient and the complete with- 
drawal of the drug at once ; secondly, by a better plan, a gradual taper- 
ing-off in the daily amount of the spirit. In either instance isolation 
must be absolute, and all smuggling of alcohol to or by the patient 

1 See author's Bedside Diagnosis. Lea & Febiger, Philadelphia. 



ALCOHOL. 81 

prevented. The attendants must be absolutely trustworthy. Care- 
ful scrutiny of bedclothes and closets will often be rewarded by find- 
ing hidden whisky bottles. The depression of the patient when recov- 
ering from alcoholism must be met by the use of nutritious broths, 
highly seasoned in order to stimulate the stomach, by easily digested or 
predigested foods, and by small doses of morphine or coca if the patient 
be very weak and need such a stimulus. Koumyss is an exceedingly 
valuable and nutritious preparation under these circumstances. 

In the treatment of the atonic stomach of drunkards a valuable aid 
is to be found in the following pill : 

R — Oleoresinae capsici TT\x (0.60). 

Olei caryophyUT nix (0.60). 

Hydrargyri chloridi mitis gr. xx (1.3). 

Aloes purificatae gr. xl (2.6). — M. 

Fiant pilulae No. xx. 

S. — One three times a day after or before meals. 

If this pill fails to move the bowels, a saline purgative may be 
used or 2 or 3 compound cathartic pills be given. 

The following are the principal points in the differential diagnosis of 

Chronic Alcoholism and the General Paralysis of the Insane. 
Chronic Alcoholism. Paretic Dementia. 

1. Attacks shorter, and more widely 1. Attacks more prolonged, 
separated by intervals of sanity. 

2. Delirium may be of any character. 2. Delirium of grandeur more marked 

and defined. 

3. Visions more characteristic, and 3. Visions often not evil, but pleas- 
are evil. ant. 

4. Tremors confined to head and arms. 4. Tremors more diffused. 

5. Tremors removed bydose of alcohol. 5. Tremors made worse by alcohol. 

6. Mental symptoms "temporarily re- 6. Mental state made worse by al- 
moved, or at any rate improved, by al- cohol. 

cohol. 

7. Tremors occur chiefly in the morn- 7. Tremors not confined to the morn- 
ing, ing. 

TJiere is danger of pneumonia from failure of the right side of the 
heart in subacute and chronic alcoholism, and the physician should 
always be on the lookout for this complication. 

Administration. — Brandy and whisky are generally used as a means 
of getting alcohol. into the body. They should be exhibited in the 
form best adapted to the work they are intended to perform. If the 
action must be instantaneous, as in a case of fainting, they should 
be employed hot and concentrated, so that the stomach has not to 
warm the liquid before absorption. They are to be used hypoder- 
mically if still more rapid action is required. If administered to aid 
digestion and support the system, then they should always be given 
with the food — never alone, and never concentrated. They may be 
given as milk-punch or as eggnogg, the latter being the "heavier" 
of the two so far as digestion is concerned. In fevers of a typhoid 
type the dose of whisky or brandy may be for an adult from \ to 2 
ounces (15.0-60.0) every three or four hours. More than a pint in 
6 



82 DRUGS. 

twenty-four hours is rarely required, but this amount often does 
great good and is not excessive if the patient is accustomed to its 
use and needs supporting treatment. When brandy or whisky is 
given to children, the following rules as to dosage may be used as 
indicating the approximate proper dose: 5 to 10 minims (0.30-0.60) 
every four hours for a child one month old; 10 to 20 minims (0.60- 
1.30) for a child two months old; 20 to 30 minims (1.3-2.0) for a 
child three months old; 30 to 40 minims (2.0-2.6) for a child over 
three months old; 60 minims (4.0) for a child over four months old. 
In some cases, however, it is well to use half these doses every two 
hours. In all cases the liquor should be diluted with hot or cool water. 
Wine-whey is very light and useful. Mulled wine and champagne 
are particularly useful in the treatment of irritable stomach. When 
milk punch is used care should be taken to shake the whisky and 
milk together before administering the mixture. Milk punch made 
with Jamaica rum is often useful. (See Foods for the Sick.) Cham- 
pagne when used as a medicinal substance should always be as devoid 
of sugar as possible — that is, what is known as " extra dry" or "Brut." 
Gin is rarely employed as a stimulant, except when the kidneys are 
torpid. Stout and porter are of value in wasting diseases, in convales- 
cence from acute diseases, and for nursing women. 

Contraindications. — All states of cerebral excitement, unless due to 
exhaustion, acute inflammations, the alcoholic habit, apoplexy, men- 
ingitis, acute nephritis, acute gastritis, hepatic congestion or inflam- 
mation, contraindicate the use of alcohol, as does also the history of 
the alcoholic habit. 

Preparations. — Dilute alcohol (Alcohol Dilutum, U. S.), pure alcohol 
(Alcohol, U. S.), and absolute alcohol (Alcohol Dehydratum, U. S., 
and Alcohol Absolutum, B. P.) are official. 

The commonly used and not official preparations of alcohol are 
as follows: 

Whisky (Spiritus Frumenti) should be at least four years old, 
and be made, in America, from rye, for medicinal purposes. 

Brandy (Spiritus Vini Gallici) is obtained by the distillation oi 
fermented grapes or fruits, and should be from three to five years 
old before use. 

Cologne-water (Spiritus Odoratus) is used solely as a lotion and 
perfume. 

Red wine is made from grapes not deprived of their skins. White 
wine is the fermented juice of grapes the skins of which have been 
removed. 

Rum, which is made from the fermentation of molasses, and con- 
tains about 40 to 45 per cent, of alcohol. 

Gin is made from rye or barley, with the addition of juniper-ber- 
ries and hops. (Good "dry " gin and the Spiritus Juniperi Composi- 
tus of the U. S. P. are virtually identical therapeutically.) When 
diuresis is required and atony of the kidneys is present, without in- 



ALMONDS. 83 

flammation, gin is a useful medicament, provided that a stimulant is 
indicated. Gin is one of the alcoholic drinks most apt to produce 
cirrhosis of the liver. 

Port Wine {Vinum Portense) is a fermented wine, to which pure 
spirit is added to increase its strength. It is one of the strongest table 
wines, and is useful as a stimulant in convalescence. 

Sherry {Vinum Xericum) has about 30 per cent, of alcohol in it. 
It is not official in the U. S. P. 

Beer is made by a slow fermentation, while ale is made by a more 
rapid fermentation at a higher heat. Most of the beer in America 
contains about 4-6 per cent, of alcohol. 

Porter resembles the other malt liquors closely, except that it con- 
tains more solids, due to a scorching of the grain by a high heat. 

The B. P. preparations that are not official in the U. S. P. are 
rectified spirit {Spiritus Rectificatus) and sherry {Vinum Xericum). 
Mistura Spiritus Vini Gallici is a useful, pleasant and nutritious 
stimulant made by beating up the yolks of two eggs with half an 
ounce of sugar, and then adding four ounces each of brandy and 
cinnamon-water. This is sometimes called " egg-flip." Dose i to 2 
ounces (30.0-60.0). 

ALLIUM. 

Garlic, or Allium Sativum, is a stimulant to digestion, owing to 
the volatile oil it contains, which by its somewhat irritating proper- 
ties excites the gastric mucous membrane to increased secretion. In 
persistent colds, where the bronchial tubes are particularly affected, a 
garlic poultice made by pounding the bulbs in a mortar, is a very 
efficient though disagreeable remedy. If the skin is too delicate to 
permit of the use of pounded garlic alone, it may be mixed with equal 
parts of bran, and a poultice or plaster made thereof. Employed 
in this form, allium is useful if applied over the spine or feet in the 
treatment of the cerebral and spinal convulsions of infants; placed 
over the belly in cases of gastro-intestinal catarrh, it acts almost as 
well as a spice poultice. In the treatment of children with chronic 
colds garlic may be used boiled in milk, and the liquid given as a 
drink, warm or cold ; or the oil of garlic may be given in emulsion 
in the dose of 1 or 2 minims (0.05-0.10). It ought not to be given 
during the febrile stage, as it is stimulating. Allium-juice has also 
been used in the dose of 2 to 5 drops (0.1-0.3) to relieve nervous 
vomiting. The dose of the syrup {Syrupus Alii) for a child is 
1 drachm (4.0), but 4 drachms (16.0) may be given to an adult. 

ALMONDS. 

Almonds are official in the form of the sweet almond {Amygdala 
Dulcis, U. S. and B.P.). Bitter almonds develop hydrocyanic acid 
in the presence of water by the reaction between the amygdalin 



84 DRUGS. 

and water in the presence of the emulsin contained in them; this 
is not the case with sweet almonds. 

Sweet almonds, when rubbed up in a mortar with water, form a 
pleasant-tasting emulsion of an agreeable odor that is very useful as a 
vehicle for remedies having a disagreeable taste. Almond bread has 
been proposed as a food for diabetics, owing to its containing virtually 
no starch; but it is requisite that the oils and saccharine constituents 
of the almond shall first be removed. (See Foods for the Sick.) 

When half an ounce of sweet almonds are rubbed up with thirty 
grains of gum arabic and two drachms of sugar, to which is added 
gradually a half-pint of distilled water, the mixture beiug then strained, 
an emollient and soothing drink is formed, which is very useful in 
irritations of the stomach and intestines and of the air-passages and 
pharynx. The expressed or fixed oil of almonds is a useful demul- 
cent, and has been recommended in the cough of phthisis, given in the 
dose of a J drachm (2.0) in emulsion. 

Bitter almonds yield an oil (Oleum Amygdalae Amarce, U. S.) which 
is exceedingly poisonous owing to the prussic acid which it contains, 
and it is said that one drop will kill a cat, while seventeen drops have 
killed a man. Oil of bitter almond should contain from 2 to 4 per 
cent, of hydrocyanic acid. 

Bitter almonds are used to allay irritable coughs and similar states, 
but are not frequently employed because other drugs are less danger- 
ous, more stable, and more active as remedial agents. The emulsion 
of bitter almonds is made as is that of sweet almonds, and may be used 
in teaspoonful doses for the same purposes and as a vehicle in cough 
mixtures. Both emulsions are useful as vehicles in the treatment 
of gonorrhoea, as they diminish the burning on urination. Almond 
emulsions, when locally applied, are supposed to be of value for the 
removal of freckles and sunburn. 

The preparations of sweet almonds are: an emulsion (Emnlsum 
Amygdake, U. S., and Mistura Amygdala, B. P.), dose 1 to 2 ounces 
(30.0-60.0); a compound powder (Pulvis Amygdala Compositus, 
B. P.), given in the dose of 1 to 2 drachms (4.0-8.0); and the oil 
(Oleum Amygdala Expressum, U. S., and Oleum Amygdala, B. P.), 
the dose of which is 1 to 4 drachms (4.0-16.0). Aqua Amygdala 
Amaras (U. S.) is prepared from the oil of bitter almonds. The dose 
is 60 to 120 minims (4.0-8.0). 

ALOES. 

Aloes, or Aloe of the U. S. P., is the inspissated juice of the leaves 
of Aloe Vera, (Linne) Webb, Aloe Chinensis Baker, Aloe Perry i Baker, 
or other species of Aloe (Fam. Liliacece). It occurs in yellowish- 
brown or orange-brown to blackish-brown opaque masses ; translu- 
cent in thin fragments ; fracture uneven, dull and waxy, somewhat 
resinous, or smooth and glassy, somewhat conchoidal ; occasionally 
exhibiting microscopic crystals of aloin ; odor characteristic ; taste 



ALOES. 



85 



nauseous, bitter. It is also probably derived from several other 
species than those just named. Aloes contains an active principle 
known as aloin (Aloinum, U. S. and B. P.), which is a crystalline 
substance. As generally sold, aloin is, however, an amorphous powder 
of extremely bitter taste. 

Physiological Action. — Locally applied to the tongue, aloes is a 
bitter of rather a persistent taste. According to the studies of Ruther- 
ford, the drug increases very considerably the flow of bile in the dog, 
but in man it cannot in any sense be regarded as a medicament for the 
production of an increased biliary flow. Rutherford's doses given to 
the dog amounted to as much as sixty grains, equal to three or four 
drachms in a man. In the lower animals and in man aloes acts very 
slowly, requiring several hours for its influence to be manifested unless 
the dose be toxic in amount. Its chief influence is on the lower 
bowel (Fig. 6), although Pfaff and Nelson assert that it also acts upon 



Fig. 6. 




A, chief effect of aloes is exercised in lower bowel or colon. 

the stomach and upper bowel. As much as 4 drachms of aloes 
have been injected into the veins of a horse without inducing purga- 
tion, probably because 4 drachms were not enough to affect the 
bowels of this animal. Aloes has been used endermically, and when 
so employed is said to act thoroughly. It is eliminated in the milk 
of nursing women, and will cause purgation in an infant put to the 
breast of a patient taking it. If the doses be quite large (10 to 20 
grains), the passages will be watery ; but if the dose be more mod- 
erate (2 or 3 grains), the stools will be thick and pultaceous. 

Therapeutics. — Aloes should be used only when a somewhat slow 
stimulant to peristaltic movement is desired, and never where the 
object of the physician is to relieve congestions by depletion through 
the intestine. It is a favorite remedy in cases of subacute or chronic 



86 DRUGS. 

constipation, but it is distinctly harmful if continued for any length 
of time, as it seems to produce atony of the bowel. Owing to its 
bitter properties it acts as a tonic to the stomach, and is often given 
with iron, as clinical experience indicates that their conjoint use is 
beneficial. Its good effects depend upon its preventing the constipa- 
tion which might be produced by the chalybeate. 

When taken in a sufficiently large dose to produce a copious pas- 
sage, aloes nearly always produces a feeling of weight and fulness in 
the region of the rectum after the evacuation, and the writer has seen 
severe rectal catarrh produced in this way in very susceptible persons. 
If given alone, it is very apt to produce griping, and it ought always 
to be combined with other drugs whose tendency is to prevent 
intestinal spasm. 

In cases of hemorrhoids in individuals suffering from general 
muscular relaxation and atony, aloes is said to do great good, but its 
use under these circumstances is by no means universal or generally 
accepted as correct. For weak, anaemic persons leading sedentary 
lives it may be combined with tonics to relieve the constipation so 
often an urgent symptom in these cases. In amenorrhcea dependent 
upon atony of the sexual system, or anaemia, or constipation, it is 
thought to have a specific emmenagogue influence. Locally applied 
in the form of the glycerole of aloes, it has been employed in the 
healing of old or recent fissures of the rectal mucous membrane, and 
even on bed-sores. The glycerole of aloes is to be made by evapora- 
ting four to eight parts of tincture of aloes and gradually adding 
thirty parts of glycerin. 

Contraindications. — Constipation occurring in plethoric persons 
should not be treated by aloes, and it should not be used if any irri- 
tation or catarrh of the intestine is present. Pregnant women should 
use aloes most carefully lest abortion be produced, and if hepatic con- 
gestion or inflammation is present it ought not to be used. Fever is 
also said to contraindicate the use of aloes, as does also rectal catarrh. 

Administration. — Aloes, U. S., is generally given in a pill, combined 
with strychnine and belladonna. (See Constipation, Part IV.) The 
dose should be 1 to 5 grains (0.06-0.3) as a laxative, and 10 grains 
(0.6) as a purge. The official preparation most commonly 
employed is the pill of aloes (Pilulce Aloes, U. S. and B. P.), 2 
grains (0.12) each of aloes and soap. The dose is one or two pills. 
Aloinum (U. S.) is given in the dose of i grain (0.015). The liquid 
preparation is the tincture (Tinctura Aloes, U. S. and B. P.), dose, 
1 to 2 fluidrachms (4.0-8.0). The official pills of the B. P. are 
the Pilula Aloes et Asafetida, Pilula Aloes et Myrrhw, and Pilula 
Aloes et Ferri. The other B. P. preparation, besides those given, is 
the Decoctum Aloes Composition, dose, § to 2 ounces (15.0-60.0). 



ALUM. 87 



ALUM. 



Alum {Alumen, U. S., and Alumen Purificatum, B. P.) is the sul- 
phate of aluminum and potassium in the U. S. P., but in the B. P. 
both it and the sulphate of aluminum and ammonium crystallized 
from a watery solution are official. At present much of the alum 
of commerce is obtained as a by-product in the manufacture of 
coal-gas for illuminating purposes, and it is therefore very cheap. 
It occurs in the form of octahedral crystals, and has an astringent 
taste and acid reaction. After the crystals are exposed to the air 
for some time they become covered with a white coating. 

Physiological Action. — When alum is brought in contact with a 
mucous membrane it produces whitening, constriction, and puckering 
of the part, and applied to the skin thickens and hardeus it by means 
of its astringent action. In either case it decreases secretion and causes 
contraction of the local bloodvessels and capillaries. Large amounts 
given internally for any length of time seem to increase secretion. 

Poisoning. — Very large amounts are necessary to produce death. 
As much as two ounces will not kill a sickly dog. This is largely due 
to the fact that the vomiting and purging rid the animal of the drug, 
for if vomiting is prevented death rapidly ensues from gastro-enteritis. 
Injected into the blood, alum produces embolism and thrombosis. 

Therapeutics. — Alum is used at present in a number of diseases, 
chiefly as a local application. In cases of ordinary sore throat appli- 
cations of a strong solution (20 grains to the ounce of water — 1.3— 
30.0) on a swab are very useful. It would be of much service in 
this condition were it not that it possesses a destructive action on the 
teeth. In hemorrhage, when the leaking bloodvessels can be directly 
reached, alum is a powerful haemostatic, aiding in the arrest of the 
bleeding in three ways — namely, by coagulating the albumin, by con- 
stringing the parts, and by crystallizing when applied in large amounts 
on lint, and thereby affording a surface which is rough and aids coag- 
ulation. In hemorrhage after tooth-extraction its application is a very 
useful treatment. Dissolved in water or alcohol, 2 grains to the ounce 
(0.1-30.0), it makes an exceedingly efficient application for sponging 
in n ight-siceats or localized sweating of the feet or hands. Used in weak 
solution in an atomizer it may be resorted to in bronchorrhoea or chron ic 
bronchitis with excessive secretion, and mchronic catarrh of the pharynx. 
In mercurial ptyalism a solution of the drug may be used on a swab. 
Bathing with an alum solution the parts affected is said to be an effi- 
cient remedy in chilblains, and for pruritus vulva 3 . As a vaginal wash 
for profuse leucorrha?a, in the strength of from 10 to 20 grains to the 
ounce (0.65-1.3 to 30.0) of water, alum is of value. Some observers 
claim good results from its use in diphtheria and tonsillitis. In 
follicular tonsillitis the alum-stick may be deeply inserted into the 
depressed follicles or applied to the swollen surface of the gland. In 
ingroicing toe-nail with granulations a piece of twisted absorbent 
cotton soaked in strong alum solution and inserted under the edge of 



88 . DRUGS. 

the nail in most instances produces a cure. A popular solution in the 
dressing of contused wounds called "Alum-Acetate Solution" is com- 
posed of 

I$— Alumini . . 5ss (2.0) 

Plumbi acetatis • 5 j (4 . 0) 

Aquse destillatse fgiv (120.0) 

Dried alum (Alumen Exsiccatum, U. S. and B. P.) is useful as a 
dressing for old ulcers and sores, and has been highly recommended 
as an application for swollen gums where they press upon and over- 
ride a tooth, particularly at the back of the jaw. The possibility of 
its exercising an evil effect on the teeth should not be forgotten. 

In the proportion of 1 ounce (30.0) of powdered alum to 1 quart (1 
litre) of warm water this drug is often efficient when used as a rectal 
injection in post-operative intestinal torpor and similar states. 

Alum may be used as an antidote in acute lead-poisoning, as it is a 
soluble sulphate and also an emetic. 

The emetic dose of powdered alum is a heaping teaspoonful for a 
child or a tablespoonful for an adult. 

Glycerinum Aluminis (1 to 6) is official in the B. P., and is used 
as a local astringent application. 

ALUMINUM ACETATE. 

Aluminum acetate (Alumini Aceias) is a useful astringent appli- 
cation in erysipelas, rhus-poisoning, boils and carbuncles in their 
formative stage, and septic injections of the hand and arm or foot 
and leg. The solution employed in the Liquor Alumini Acetatis of 
the National Formulary diluted in the proportion of 1 to 7. 

ALYPIN. 

Alypin is used as a local anaesthetic and appears in the form of a 
white crystalline powder, readily soluble in water and in alcohol, the 
solution being neutral in reaction. It is a glycerine derivative, tech- 
nically called the monohydrochloride of benzoyl. Solutions of it can 
be sterilized by boiling, provided the heating does not extend beyond 
five minutes. It is claimed to be equal in power to cocaine for the 
production of anaesthesia, and is commonly employed in freshly pre- 
pared 2 per cent, solution in the eye and in 10 per cent, solution on 
other parts. When dropped into the eye it is said not to cause myd- 
riasis nor affect accommodation. It does not constrict local bloodvessels, 
which is advantageous in some cases and disadvantageous in others ; 
thus, in operations upon engorged nasal mucous membranes it fails to 
open the field of operation. The secondary congestion so characteristic 
of cocaine is said to occur in an exaggerated form after the anaesthetic 
effect of alypin. Solutions of alypin, with or without adrenalin, may 
be employed for infiltration anaesthesia by Schleich's method. Alypin 
is less irritating than eucaine when dropped in the eye. (See Cocaine.) 



AMMONIA. 89 



AMBER. 



Succinum is derived from a fossil resin found in Prussia and in 
Bohemia, and is used in the form of the oil {Oleum Succini), which is 
volatile, quite irritant, and obtained by destructive distillation from 
the deposit named. 

Therapeutics. — Oil of Amber is one of the best remedies for per- 
sistent hiccough that we have. It is very useful as a counterirritant 
over rheumatic joints, and has been used in asthma, whooping-cough, 
and hysteria with good results. In the bronchitis of infants, with 
nervous disturbance, oil of amber in the proportion of 1 to 3 parts 
of olive oil applied to the back and front of the chest is of service. 
In adults suffering from acute laryngitis with extension of tjtie inflam- 
mation into the bronchial tubes, full of doses of sodium bromide given 
internally, with this proportion of amber oil and olive oil rubbed into 
the neck and chest, are useful. The dose internally is 2 to 6 minims 
(0.1-0.4) given in emulsion. 

AMMONIA (NH 3 ). 

Ammonia is a gas of a very acrid, burning taste, capable of produc- 
ing death very rapidly when inhaled, by reason of the inflammation 
of the air-passages and the spasm of the glottis which ensue. It is 
made in large amounts in the manufacture of coal-gas. 

Physiological Action. — When ammonia comes in contact with the 
tissues of the body it acts as a most powerful irritant, causing a red- 
dening of the parts, followed, if the exposure be sufficiently pro- 
longed, by local death and sloughing. If it be inhaled as a gas, it 
may produce rapid death by spasm or oedema of the glottis, and 
if a strong solution of it is swallowed, the same accident may 
occur. Following more moderate inhalations severe bronchitis or 
pulmonary oedema may develop. 

Nervous System. — If ammonia be injected into the blood of 
animals, violent convulsions at once ensue which are largely tetanic 
in type and depend upon a spinal action of the drug, since they 
are not stopped by division of the spinal cord, as they would be if 
the convulsive movements had their origin in the brain. The 
drug in moderate amounts acts as a spinal excitant, increasing re- 
flex action and all the evidences of spinal activity. If applied 
directly to a nerve, either motor or sensory, it paralyzes the nerve ; 
but if the drug be in a very weak solution, it seems to increase the 
functional activity of the nerve. 

Circulation. — Upon the circulation ammonia acts as a power- 
ful but fleeting stimulant, increasing the pulse-rate, pulse-force, and 
arterial pressure. The cause of the increased pulse-rate depends 
upon stimulation of the accelerator nerves of the heart and of the 
heart itself, while the increase in force is due to the same cause, 
for Ringer and Sainsbury found the strength of the ventricles 
much increased. The rise of arterial pressure is due to the in- 



90 



DRUGS. 



Fig. 7. 



creased amount of blood pumped into the arteries by the stimu- 
lated heart, and probably by a stimulant action on the vasomotor 
centre, although this is denied by some authorities. As the drug 
acts as a stimulant on the respiratory centre, which is very near the 
vasomotor centre, it probably increases the functional activity of both. 
If by means of intravenous injection the ammonia reaches the heart 
in large amount in concentrated form, this organ ceases to beat at 
once, owing to paralysis of its muscular walls. 

The Blood. — In moderate amounts the drug has no effect on the 
blood, but when injected in poisonous quantities it causes the blood 
to fail to take up the oxygen, according to Feltz and Ritter. 

Respiration. — The injection of ammonia in moderate quantities 
into the blood causes an acceleration of the rate of respiration due to 
stimulation of the respiratory centre, the respiratory movements 
becoming not only more full, but also more rapid. If the drug is 
inhaled in small amounts or swallowed, the same action is seen in 

a less degree, the changes both in 
breathing and circulation being partly 
due under such circumstances to a 
reflex irritation transmitted along the 
sensory nerves. 

Elimination. — Ammonia when 
taken into the body is so extremely 
fleeting in its action that the question 
as to its escape from the system is of 
interest. If large amounts are taken, 
it is partly given off by the breath, 
but more of it is destroyed in the 
system, and according to Bence 
Jones,, eliminated as nitric acid by 
reason of its being oxidized in the 
body. The greater part, however, is 
excreted as urea. 

Therapeutics. — Ammonia is em- 
ployed for four distinct purposes in 
medicine — namely, as a circulatory 
and respiratory stimulant, as a 
counterirritant, and as an antacid. 

The indications for the use of 
ammonia in the first class of cases 
are all forms of sudden cardiac failure where there is no time or op- 
portunity to use the more stable and slowly acting drugs. These 
emergencies occur in snake poisoning, in syncope from fright or other 
shock, or from indigestion, in sudden cardiac failure during the course 
of fevers and in pneumonia, and in all cases where prompt cardiac stim- 
ulation is needed. In the most pressing cases it should be injected 
directly into a vein of the leg, so as to act more quickly. If put 




Ammonia stimulates: A, the accel- 
erator nerves; B, the heart-muscle 
itself, and so quickens pulse-rate and 
force. It stimulates the vasomotor 
centre C and the respiratory centre D. 



AMMONIA. 91 

into the subcutaneous tissues, it is almost certain to cause a slough, 
and if injected into a vein of the arm, it may reach the heart in too 
concentrated form and cause cardiac depression, Ringer has found 
that the drug has the extraordinary power of causing a heart stopped 
or depressed by chloroform to resume its beating. It is claimed, with- 
out much justification, that ammonia will aid in preventing heart-clot 
or thrombosis in cases of severe hemorrhage and in pneumonia. 

In prolonged diseases the employment of ammonia is not particu- 
larly advisable, owing to its fugacious action, although it is largely 
used, for the frequent administration necessarily required is apt to 
produce gastric disorder. Some writers claim that ammonia is useful 
as a sedative in drunkenness, but this is doubtful. 

In gastric acidity due to fermentation, with the development of 
abnormal acids, ammonia is the most active remedy we can employ, 
but it is not to be given if acute irritation of the stomach exists. 

Locally applied, strong ammonia-water may be used to produce a 
blister by placing a few drops on the skin under an inverted watch- 
glass. Ammonia-water may also be applied, often with great relief, 
to the spot stung by insects. The waters of ammonia are used exter- 
nally in stimulating liniments, and hypodermically when the drug is 
so given. The stronger water ought not to be employed for the latter 
purpose. The aromatic spirit is generally used internally in the dose 
of \ drachm to 1 drachm (2.0—4.0), well diluted. This is also the 
dose of the ordinary spirit. 

Administration. — Ammonia is never employed in medicine as pure 
ammonia gas, but in the form of the stronger water (Aqua Ammonia? 
Fortior, U. S., Liquor Ammonia Fortis, B. P.), containing not less than 
27 per cent, nor more than 29 per cent. (32.5 per cent., B. P.), by weight 
of the gas, and the weaker water (Aqua Ammonia 3 , U. S., Liquor 
Ammonia, B. P.), which should contain not less than 9.5 per cent, 
nor more than 10.5 per cent, by weight of the gas. The aromatic 
spirit of ammonia (Spiritus Ammonia? Aromaticus,AI. S. and B. P.) 
is given in the dose of 30 to 60 minims (2.0-4.0) in water. The latter 
preparation is composed of carbonate of ammonium, the oils of 
nutmeg, lemon, and lavender, with alcohol and ammonia-water. 
Spiritus Ammonia? F&tidus (B. P.) contains asafcetida, and is used 
in place of the aromatic spirit. Ammonia liniment (Linimentum 
Ammonia 3 , U. S. and B. P.) is used over tender joints and muscles. 

AMMONIAC. 

Ammoniac (Ammoniacum, B. P.) is a resinous gum obtained from 
Dorema Ammoniacum, and is little used in medicine at the present 
time. Internally and externally it produces some irritation when 
brought in contact with the tissues, and may be used internally in the 
dose of 10 to 30 grains (0.60-2.0) in pills in cases of chronic bron- 
chitis devoid of any active inflammatory process. Mistura Ammoniaci 
(B. P.) is used in chronic bronchitis in the dose of from J to 1 fluid- 
ounce (15.0-30.0). 



92 DRUGS. 

AMMONIUM (NH 4 ). 

The following salts of ammonium are official, and are used for 
various purposes: 

Acetate of Ammonium. 

Acetate of Ammonium is used in medicine in the form of the 
spirit of Mindererus (Liquor Ammonii Acetatis, U. S. and B. P.), 
dose 1 to 2 fluidrachms (4.0-8.0), 2 to 6 fluidrachms (8.0-24.0), B. P., 
for the purpose of acting as an antacid in gastric indigestion, and also 
as a mild diaphoretic which is inferior to sweet spirit of nitre. 

Benzoate of Ammonium. 

Benzoate of Ammonium (Ammonii Benzoas, U. S. and B. P.), 
should contain not less than 98 per cent, of pure Ammonia Ben- 
zoate [C 6 H5.COONH 4 ], and should be kept in well-stoppered bottles. 

It occurs in thin, white, laminar crystals or a crystalline powder; 
odorless or having a slight odor of benzoic acid, a saline, bitter, after- 
ward slightly acrid taste, and gradually losing ammonia on exposure 
to the air. One Gm. is soluble in about 10 mils, of water and 35.5 
parts of alcohol and about 8 mils, of glycerin at 25° C. (77° F.). 

It is employed chiefly for its diuretic influences, which depend 
entirely upon the benzoic acid present in the compound. As benzoic 
acid is eliminated as hippuric acid and ammonia as nitric acid, this 
drug may be employed in cases where the physician desires to make 
the urine decidedly acid; as, for example, in patients suffering from 
catarrh of the bladder, when the urine is loaded with phosphates, 
which are dissolved by this acidulation. It is useful in certain cases 
of muscular rheumatism. The dose is 10 to 30 grains (0.60-2.0), 
which should be suspended in water or, better, administered in cachets 
or capsules. 

Bromide of Ammonium. 

Bromide of Ammonium (Ammonii Bromidum, U. S. and B. P.), 
should contain not less than 98.5 per cent, of pure Ammonium 
Bromide, and should be kept in well-stoppered bottles. 

It occurs as colorless, transparent, prismatic crystals, or a white, 
crystalline powder; odorless, of a pungent, saline taste, and perma- 
nent in dry air and is soluble in 1.3 parts of water, and in 12 parts 
of alcohol at 25° C. (77° F.), in 0.9 part of boiling water, and in 1.2 
parts of boiling alcohol. 

It is, however, generally found in commerce as a white granular 
powder, which, when exposed to the atmosphere, becomes slightly 
yellowish. 

Physiological Action.— Applied to the mucous membrane of the 



AMMONIUM. 93 

mouth, bromide of ammonium produces a salty taste, is markedly 
pungent, and dissolves readily in the oral secretions. If large amounts 
are swallowed, it causes burning pain in the belly and evidences of 
gastro-enteritis. 

Nervous System. — The action of this drug upon this part of the 
body is its most important effect. Given to the lower animals, it pro- 
duces in frogs total loss of reflex activity, preceded, it is said, in some 
cases by tetanic convulsions, although no such motor disturbances may 
take place. In a series of studies undertaken by the writer to deter- 
mine the effect of the drug it was found that the spinal cord was de- 
pressed, both on its motor and sensory sides, while the nerves and mus- 
cles escaped. These results are in accord with those of other investi- 
gators, who also found that the nerves are unaffected. On the cere- 
bral cortex it acts as a distinct sedative. (See Bromide of Potassium). 

Circulation. — Upon the circulation bromide of ammonium acts 
as a stimulant in small doses, but as a cardiac paralyzant if a large 
amount comes in contact with the heart. In medicinal dose it is dis- 
tinctly stimulant to the circulation, but not sufficiently so to render 
it valuable as a circulatory stimulant, to the exclusion of other more 
powerful preparations. 

Therapeutics. — The bromide of ammonium may be used in nearly 
every instance where bromide of potassium may be employed, and 
possesses the distinct advantage of being less depressant to the gen- 
eral system than the latter drug. It is, however, more apt to disorder 
the stomach even if given in moderate doses. In epilepsy it would 
seem to be of as much value as the potassium salt, and may be combined 
with it in some cases with success. (See article on Epilepsy, Part 
IV.) According to J. M. Da Costa, the drug is of distinct value 
in rheumatism in the dose of 60 to 80 grains (4.0-5.3) a day, well 
diluted with water, although its manner of action in this disease is 
not known. The usual dose is 10 to 30 grains (0.60-2.0). It is in- 
compatible with spirit of nitrous ether. 

Ammonium Carbonate. 

Ammonium Carbouate (Ammonii Carbonas, U. S. and B. P.), 
should contain not less than 97 per cent of a mixture of Acid Am- 
monium Carbonate and Ammonium Carbamate and should yield not 
less than 30 per cent, of ammonia gas. It should be kept in well- 
stoppered bottles, in a cool place. For dispensing purposes, only the 
translucent portions should be used. 

It occurs in white, hard, translucent, striated masses, having a 
strong odor of ammonia without empyreuma and a sharp saline taste. 
On exposure to the air, the salt loses both ammonia and carbon 
dioxide, becoming opaque, and is finally converted into friable, 
porous lumps or a white powder. 

It is slowly but completely soluble in about 4 parts of water at 25° 



94 DRUGS. 

C. (77° F.), and is decomposed by hot water, with the elimination of 
carbon dioxide and ammonia. By prolonged boiling with water, the 
salt is completely volatilized. 

It undoubtedly has an action exactly like that of the liquid prepara- 
tions of ammonia, and is used either alone or with the chloride in the 
treatment of bronchitis, particularly when this disease occurs in babies 
and young children. Ammonium carbonate is also largely employed 
by surgeons in the treatment of children after a surgical operation 
to overcome the respiratory and circulatory depression produced by 
the anaesthetic. The dose is 2 to 10 grains (0.12-0.60) in syrup of 
acacia and water. It is a rapidly acting cardiac and respiratory 
stimulant. 

1$ — Ammonii carbonatis gr. xlviij (3 2) 

Syrupi acaciae f 5 (30 . 0) 

Aquse destillatse q. s. ad giij (90.0). — M. 

S. — Teaspoonful (4.0) every two hours in water for a child of three or four years. 

Ammonium Chloride. 

Ammonium Chloride or Muriate (Ammonii Chhridum, U. S. and 
B. P.). It should contain not less than 99.5 per cent, of pure Am- 
monium Chloride. It occurs as a white, crystalline powder, without 
odor, having a cooling, saline taste, and is somewhat hygroscopic. It 
is soluble in 2.6 parts of water, in 100 parts of alcohol, and in 8 parts of 
glycerin, at 25° C. (77° F.), and in 1.4 parts of boiling water. The 
aqueous solution of the salt (1 in 20) in ice-cold water, should not 
redden blue litmus paper at once ; it affords, with silver nitrate a 
white, sandy precipitate, which is soluble in ammonia water. 

Ammonium chloride has an entirely different action and therapeu- 
tic use from the rest of this group. It possesses almost no influence 
over the heart and respiration, but does exercise a very stimulant 
effect on mucous membranes, increasing the secretion of mucus. 
The consideration of its use in diseases of the lungs can be found 
in the articles on Pneumonia and Bronchitis. Chloride of ammonium 
fumes can be obtained .from a few grains of the drug heated in an 
iron spoon over a gas-jet or by means of a set of three wash-bottles. 
In one of these is placed stronger water of ammonia, in another hydro- 
chloric acid. Each of these is connected with a third bottle by means of 
glass tubing, this bottle being partly filled with water, through which 
the fumes in passing become purified and form the fumes of chloride 
of ammonium. The drug may also be used in a spray from an 
atomizer. Where it is desirable to maintain the effect of the drug 
over a long period of time, as in chronic bronchitis, the following 
method may be followed, as recommended by Mew : A soup-plate 
is placed upon the floor of the room, and from 3 to 4 ounces (90.0-120.0) 
of sulphuric acid are placed in it. Into a neighboring saucer are 
poured 2 ounces (60.0) of strong ammonia, and then about a table- 



AMMONIUM. 95 

spoonful (15.0) of ordinary table salt is sprinkled upon the acid. In 
less than a minute the room becomes filled with dense fumes of 
nascent chloride of ammonium, which can be readily maintained by 
renewed charging of the soup-plate and saucer. In this way the 
patient may be made to inhale chloride of ammoniiun fumes for a 
long period of time with very advantageous results. This is a par- 
ticularly useful method in cases of fetid bronchitis. 

Chloride of ammonium has been employed in intermittent fever, but 
has gone out of use, and has also been used in neuralgias of the 
ovarian type by Goodell and others. In the treatment of chronic 
torpor of the liver and subacute hepatitis, and even in cirrhosis and 
hepatic abscess, it has been thought of value. Many clinicians have 
found it useful in the treatment of the gastric and intestinal catarrhs 
of children of a very subacute type, and it is the routine treatment for 
all such cases which come under observation at the hospital and else- 
where where the author has charge. The dose is 2 to 15 grains 
(0.12-1.0), preferably given with liquorice and water to mask the 
taste. 

I$— Ammonii chloridi 5ij (8.0). 

Fluidextracti glycyrrhizae . . f 5j (30.0). 

Aquae destillatae q. s. ad f§iij (90.0).— M. 

S.— Teaspoonful (4.0) t. i. d. in water after meals for a child of five or ten years. 

The chloride of ammonium may, however, be given in compressed 
tablets, provided a large draught of water or milk is taken simulta- 
neously to protect the stomach. (See article on Bronchitis for other 
prescriptions.) 

Gillespie asserts that 10 grains (0.60) of chloride of ammonium 
given half an hour before meals gives extraordinary relief in painful 
dyspepsia due to hyperacidity of the stomach. 

Chloride of ammonium, in a lotion of the strength of 1 ounce 
(30.0) to 3 quarts (3 litres) of water, is an efficient remedy for the 
dermatitis caused by poison-ivy. 

Ammonium Iodide. 

Ammonium Iodide (Ammonii Iodidum, U. S.) should contain not 
less than 99 per cent, of pure Ammonium Iodide, and should be kept 
in small amber-colored, well-stoppered vials, protected from light. 

AVhen deeply colored, the salt should not be dispensed, but it may 
be deprived of free iodine by adding to its concentrated aqueous 
solution sufficient ammonium sulphide to render it colorless, then 
filtering, and evaporating on a water-bath to dryness. It occurs 
in minute, colorless, cubical crystals or a white, granular powder, 
without odor when colorless, but emitting a slight odor of iodine 
when colored, and having a sharp, saline taste. The salt is very 
hygroscopic, and soon becomes yellow or yellowish-brown on expo- 
sure to the air and light, owing to the loss of ammonia and the 



96 DRUGS. 

liberation of iodine. It is soluble in 0.6 part of water, and in 3.7 
parts of alcohol at 25° C. (77° F.) ; in 0.5 part of boiling water, and in 
1.5 part of glycerin. 

Ammonium Valerate. 

Ammonium Valerate (Ammonii Valeras, U. S.), should contain 
not less than 98 per cent, of pure Ammonium Valerate, and should 
be kept in well-stoppered bottles. It occurs in colorless, or white, 
quadrangular plates, emitting the odor of valeric acid, of a sharp 
and sweetish taste, and deliquescent in moist air. It is very soluble 
in water and in alcohol ; also soluble in ether. 

This is the salt of ammonium commonly used in the nervous 
unrest of pregnant or hysterical women, or at the menopause in the 
peculiar nervous disorders apt to occur at that period. In poisonous 
doses it paralyzes the spinal cord in the lower animals. It is usually 
given in the form of the elixir of valerate of ammonium, the dose of 
which is a teaspoonful to a dessertspoonful, or it is~ combined with the 
bromides, under which circumstances it is much more efficacious. 
The dose of the salt itself is 10 to 15 grains (0.60-1.0). 

The sulphate of ammonium is never used in medicine. The 
phosphate of ammonium is employed in rheumatism in the dose of 
10 to 20 grains (0.60-1.3). It is no longer official. 

The B. P. preparations besides those already given are : Phosphate 
of Ammonium,, dose 5 to 20 grains (0.3-1.2), and Liquor Ammonii 
Citratis, dose 2 to 6 fluidrachms (8.0-24.0). 

AMYL NITRITE. 

Amyl Nitrite (Amijlis Nitris, U. S., Amyl Nitris, B. P.) is a liquid 
containing about 80 per cent, of Amyl (chiefly Iso-amyl) Nitrite [C 5 - 
H^NOJ . It should be kept in hermetically sealed glass bulbs, or in 
dark amber-colored, glass-stoppered vials, in a cool and dark place. 
It is a clear, yellowish liquid of a peculiar, ethereal, fruity odor, and 
pungent, aromatic taste. It is almost insoluble in water; miscible, 
in all proportions, with alcohol or ether. 

Amyl nitrite is very volatile, even at a low temperature, and is in- 
flammable, burning with a yellow, luminous and sooty flame. It boils 
at about 96° to 99° C. (204.8° to 210.2° F,). It is made by the 
action of diluted sulphuric acid upon amy lie alcohol and sodium nitrite. 
It is not to be confounded with nitrate of amyl, which has a different 
physiological action and is never used medicinally. 

Physiological Action. — When swallowed or inhaled, the drug pro- 
duces staggering, fulness in the head, roaring in the ears, duskiness 
of the face, and finally complete muscular relaxation, so that the 
animal or man falls to the ground. The heart beats very rapidly 
and forcibly, and the respiration becomes gasping. 



AMYL NITRITE. 



97 



Fig. 8. 




V 



V 



Nervous System. — Nitrite of amyl is the most rapidly acting of 
all the nervous depressants and sedatives which are used as medi- 
cines, except prussic acid. Experiments show that its dominant 
action is on the motor side of the spinal cord. The motor cortex of 
the brain and the motor nerves are only affected by large amounts. 
Upon the nervous apparatus of sensation nitrite of amyl has no 
effect in medicinal amounts, and should never be used to relieve pain 
unless it be due to spasm or to angina pectoris. The 
muscles are depressed by toxic amounts. 

Circulation. — When nitrite of amyl is used, the 
pulse becomes exceedingly rapid while the arterial 
tension speedily falls. The increase in pulse-rate 
is due to depression of the centric inhibitory appa- 
ratus (vagus centres) of the heart and to the sudden 
relaxation of the bloodvessels, by reason of which, 
the resistance being taken away, the heart beats 
faster. The fall of arterial pressure is chiefly due 
to depression of the muscular coats of the blood- 
vessels and also to slight depression of the vaso- 
motor centres, but the bloodvessels of the pul- 
monary system are constricted by the nitrites. 
In very small amounts the drug stimulates the 
heart-muscle (Reichert), but its dominant action 
on the heart is that of a depressant. 

The Blood. — In large medicinal dose this drug 
produces a chocolate color of the arterial blood, 
to the change of oxyhemoglobin into methemo- depresses the motor 

fflobill or crosse d pyramidal 

T - -r, . tracts of the spinal 

L rine and Elimination. — 1 he urine sometimes C ord. 
contains sugar after the use of nitrite of amyl, and 
there is increased diuresis. The drug is eliminated very rapidly from 
the body by the lungs and kidneys. 

Temperature.— If the nitrite of amyl be employed for any length 
of time, a most remarkable fall in bodily temperature ensues, which 
is probably due to diminished oxidation, but possibly to some effect 
on the heart-centres governing heat-production and dissipation. The 
vascular dilatation also tends to aid greatly in the loss of bodily heat 
produced by the drug. 

Therapeutics. — Nitrite of amyl is used to relax general or local 
muscular spasms, for the relaxation of the spasm of epilepsy and for 
aborting an on-coming fit, for the prevention and subjugation of 
strychnine convulsions and tetanus, and for the relief of angina pec- 
toris, provided the attack is accompanied by high arterial tension. It 
may be used in puerperal eclampsia, but it is a dangerous remedy 
because of its relaxation of the uterus aud the consequent danger of 
post-partum hemorrhage, Nitrite of amyl by inhalation is the best 
remedy to check haemoptysis, because it constricts the pulmonary 
7 



v 



Nitrite of Amyl 



98 DRUGS. 

vessels and simultaneously relaxes the systemic circulation, thereby 
diminishing the flow of blood to the lungs. In dysmenorrhea with 
uterine spasm it often gives great relief. Nitrite of amyl has been 
used in cases of seasickness as a prophylactic and cure with consider- 
able success. In cardiac failure from fright or anaesthetics amyl 
nitrite is of some value when given in single whiffs. If it does not 
act at once under these circumstances, it is worse than useless to 
push it. It has also been found of value in whooping-cough, laryn- 
gismus stridulus, asthma, spasmodic croup, and infantile convulsions. 
In migraine, with local vasomotor spasm and true hemicrania, it is 
very useful. In strychnine-poisoning and tetanus it must be inhaled 
between the spasms or else given hypodermically, as the respiratory 
cramp prevents its inhalation. 

Administration. — The drug may be given by placing three to five 
drops on a handkerchief and inhaling the fumes, or it may be drop- 
ped on sugar and taken by the mouth in the same quantity. The 
best way for patients to use the drug is to have it in hollow pearls of 
glass, each holding 5 or 10 minims (0.3-0.06). One or more of 
these may be crushed in a handkerchief and the fumes inhaled. 

It is important to remember the fact that the effects of the drug 
are more severe for a moment after its use than during its inhalation. 
The physician should warn the patient that the effect of the drug is 
sudden and alarming, and in nervous cases should direct that the 
inhalations be made slowly, as a very full inhalation may produce 
unpleasant sensations of cardiac oppression. 



ANTHRAROBIN. 

Anthrarobin seems to possess equal value with its relative chrys- 
arobin, and to be capable of acting as efficaciously as this substance 
in the treatment of skin diseases. It is a yellowish powder, tolera- 
bly stable in a dry atmosphere, not soluble in acids or water, but 
readily soluble in dilute alkaline solution or alcohol, at first making a 
solution of a brown color, which, as oxygen is taken up, changes to a 
green and finally to a violet hue. 

Therapeutically, anthrarobin has been employed by Rosenthal and 
by Behrend, and more recently Kobner has recorded his experience 
with it, employing it with good results in a 10 to 20 per cent, solu- 
tion in the various forms of tonsurans as a wash. Rosenthal has 
used it in psoriasis an pityriasis versicolor and herpes, and Behrend 
asserts that it is often better in its effects upon the skin than chrysa- 
robin, as it produces less inflammation and discolors the skin only 
slightly. It also possesses the additional value of making so slight a 
stain on the linen that it can be removed by washing. 

According to most authorities, it is best to keep the drug in alco- 
holic solution, and, if the bottle is well corked, such a mixture 
remains stable for a week. 



ANTIMONY. 



99 



Fig. 9. 



ANTIMONY. 

Antimony itself is rarely used in medicine, owing to its insolu- 
bility, but is generally employed as the tartrate of antimony and 
potassium, or Tartar Emetic 
(Antimonii et Potassii Tartras, 
U. S.; Antimonium Tartratum, 
B. P.), or in the form of the 
sulphide (Antimonii Sulphi- 
dum); purified sulphide (Anti- 
monii Sidphidum Purificatum; 
Antimonium Nigrum Piirifica- 
tum, B. P.); and sulphurated 
antimony (Antimonium Sul- 
phuratum, B. P.), sometimes 
called Kermes Mineral. The 
last three drugs are very rarely 
employed and are unreliable 
preparations, although some 
practitioners use kermes min- 
eral as an alterative circulatory 
depressant and sedative expec- 
torant in the dose of \ grain 
(0.01) every hour or two. As 
an emetic the dose of Kermes 
Mineral is 1 to 4 grains (0.06- 
0.25). 

The oxide of antimony (Anti- 
monii Oxidum, B. P.) forms 
part of the Pulvis Antimonialis. 

Tartar Emetic. 

Tartar Emetic (Antimonii et 
Potassii Tartras, U. S.; Anti- 
monium Tartaratum, B. P.) is 
made by boiling the oxide of anti- 
mony with bitartrate of potas- 
sium and water. Although it is 
really crystalline, it is generally sold as a fine powder owing to the 
crystals being easily pulverized. It should contain not less than 98.5 
per cent, of pure Antimony and Potassium Tartrate and occurs as 
colorless, transparent crystals of the rhombic system, becoming 
opaque and white on exposure to air, or as a wmite, granular powder; 
without odor, and having a sweet, afterward disagreeable metallic 
taste. It is soluble in 12 parts of water at 25° C. (77° F.), and in 




A, antimony depresses the heart-muscle; 
B, antimony depresses the peripheral por- 
tions of the vasomotor system in the blood- 
vessels; C, antimony depresses the vasomo- 
tor centre; D, the respiratory centre. 



100 



DRUGS. 



3 parts of boiling water, but insoluble in alcohol, which precipitates 
it from its aqueous solution in the form of a crystalline powder. 

Owing to its chemical constitution tartar emetic should never be 
given with either acids or alkalies, and all drugs containing tannic 
acid are also incompatible with it, owing to the fact that an insoluble 
t annate is rapidly formed, which is absorbed very slowly if at all. 
So complete is the insolubility of the compound so formed that 
tannic acid is the best chemical antidote to the drug that we possess. 
Physiological Action. — Tartar emetic, when applied to mucous 
membranes, produces a burning sensation, and upon the skin it may 
readily cause intense irritation if the part be delicate. If kept in 
contact with a mucous membrane, very distinct inflammatory changes 
occur, and if it be applied to the skin for any length of time, red- 
ness, followed by acne of a pustular character, appears, which finally 
ends in ulceration and sloughing if the use of the drug is persisted 
in. Under these circumstances the vitality of the parts seems inter- 
fered with, and, as a result, healing takes place very slowly indeed. 
Nervous System. — Antimony is a depressant to the sensory side 
of the spinal cord, and a paralyzant to all the spinal centres, motor 
and sensory, in poisonous dose. 

It is stated that when an animal is under its influence sensation to 
heat and acids is lost before the ordinary sense of touch is destroyed. 

The convulsions which sometimes 
ensue after poisonous doses in the 
lower animals are due to anaemia of 
the brain brought on by the circu- 
latory depression. Ringer and Mur- 
rell have -proved antimony to be 
a motor-nerve and muscle poison. 

Circulation. — The chief influ- 
ence of antimony is exerted upon 
the circulation. In small doses it 
lowers the pulse-rate by a direct 
depression of the heart-muscle, and 
simultaneously decreases arterial ten- 
sion by an action upon the peri- 
pheral portions of the vasomotor 
system in the walls of the bloodves- 
sels, but the vasomotor influences 
may be in part centric, and this 
question must be considered as sub 
judice. The fall of arterial pressure 
is also due to failure of heart- force. With the lowering of the pulse- 
rate there is nearly always a corresponding decrease in cardiac power. 
When poisonous doses are employed, death ensues after great cir- 
culatory and respiratory depression, as will be seen below. . The 



Fig. 10. 





A, antimony stimulates the vomiting 
centre; B, antimony irritates the gas- 
tric mucous membrane. 



ANTIMONY. * 101 

heart is found after death relaxed and flabby and wholly unrespon- 
sive to all stimuli, although in one of the lower animals, such as the 
frog, if the dose has not been very excessive and digitalis is freely 
employed, the heart may be made to beat again. In man, it is 
hardly necessary to state, the digitalis must be used early to render 
much service. The drug in poisonous doses is thought to depress the 
peripheral ends of the vagus nerves. 

Respiration. — The drug has little or no effect upon respiration 
except when given in lethal doses. Under these circumstances death 
is produced in three ways, all of them acting together. Primarily, 
the respiratory centre iu the medulla is depressed, and the governing 
nerves of breathing, the pueumogastrics, are also rendered inactive ; 
secondarily, the cardiac failure speedily causes pulmonary congestion ; 
and, thirdly, the drug causes such an outpouring of liquid mucus into 
the bronchial tubes that the patient is drowned in his own secretions, 
which he is too weak to expel. 

Stomach and Intestines. — Antimony in toxic doses is a powerful 
irritant to these portions of the body. In full medicinal amounts it acts 
as a slow but powerful emetic, producing much nausea. The vomiting 
is due to an action on the vomiting centre in the medulla and to a direct 
action on the stomach itself. The drug is, therefore, a centric and 
peripheral emetic. Very full doses produce watery purging, attended 
with some griping and tenesmus. 

Elimination. — Antimony escapes from the body in all the secre- 
tions, but largely by the bowels. The latter method of elimination 
seems chiefly to follow poisonous doses, and purging is an effort at 
elimination. 

Therapeutics. — Tartar emetic is employed for at least five separate 
purposes, the most usual of which is as a circulatory quieter and seda- 
tive. The indications for antimony as a circulatory depressant are not 
so generally recognized at present as they were at one ttme, on 
account of the introduction of other drugs. All states of sthenic in- 
flammation with a bounding pulse, high fever, and symptoms show- 
ing the patient to be possessed of robust constitution permit of its 
use, while all asthenic conditions most emphatically contraindicate its 
employment. In the treatment of colds, to break forming diseases, 
and to allay inflammation it is given in moderate dose. It is useful 
in sthenic bronchitis as an expectorant. Under these circumstances it 
may be given in emetic dose; or, if emesis is not desirable, minute 
amounts given hourly are of value, such as ^ F grain (0.001) every 
hour, or a teaspoonful of a solution of \ grain (0.03) to 4 ounces 
(120 mils.) of water every hour may be used. This is a particularly 
useful method in children, as the solution is tasteless and it does not 
produce nausea and vomiting. 

Most modern practitioners have ceased to use this drug because the 
depressant plan of treatment is out of favor, and because the effects 
of the vegetable cardiac sedatives are more easily controlled. 



102 DRUGS. 

As an emetic antimony is slow but forcible. It ought not to be 
used in cases of poisoning by other drugs, owing to its depressant 
effects and slowness of action. 

Before the introduction of anaesthetics emetic doses were employed 
to relax the muscles in reducing dislocations and fractures. 

Tartar emetic is harmful if irritation of the stomach is pre- 
sent or if renal inflammation is present. If one good-sized emetic 
dose is not sufficient to produce vomiting, it should not be 
repeated, but some other emetic or the stomach-pump be used, 
lest antimonial poisoning complicate the case. The emetic dose must 
be large enough to be effective, or none at all should be given. If 
this rule is disregarded, systemic changes come on with undesirable 
severity in those cases where emesis fails to occur because of small 
doses. 

As a counterirritani antimony is employed in the form of an oint- 
ment whenever a very slowly acting and prolonged counter irritation 
is to be maintained, as on the back of the neck in epilepsy or similar 
chronic states, and in old enlargements of the joints. 

Antimony is an efficient diaphoretic, but its use is undesirable, 
owing to its disagreeable effects, such as nausea and intestinal dis- 
turbance, and because other, more pleasant, drugs act equally well. 

Administration. — The dose of tartar emetic when there is an 
excited circulation is -^V to ro grain (0.003-0.006) every three hours 
until an effect is obtained. As an emetic the dose is \ to 1 grain 
(0.03-0.06). The compound pill of antimony (Piluloe Antimonii 
Composite, or Plummer's pill) is used as an alterative, and contains 
sulphurated antimony \ grain (0.03), calomel \ grain (0.03), guaiac 
1 grain (0.06); the dose is one to three pills. 

The ointment of antimony (TJnguentum Antimonii Tartarati) is 
used externally as a counterirritant spread on a rag or piece of lint. 
Antimonial powder (Pulvis Antimonialis, B. P.), or James's powder, 
contains oxide of antimony and phosphate of calcium, and is given 
occasionally as an antipyretic in the treatment of rheumatism and fever 
in the dose of 3 to 6 grains (0.20-0.40) ; it is best given in a pill. 

The compound syrup of squill (Syrupus Scillre Compositus, U. S.), 
otherwise known as " Coxe's Hive Syrup," contains f grain (0.045) 
of tartar emetic to the ounce. The dose is 20 to 30 minims (1.3-2.0) 
for an adult as a sedative, or from this amount to 1 drachm (4.0) 
to a child as an emetic. 

Poisoning. — When toxic doses of tartar emetic are taken, the pulse 
at first becomes slightly weaker and slower, the skin becomes moist and 
relaxed, a general sense of relaxation comes on, and simultaneously a 
sensation of severe nausea and gastric distress appears. 

Following this condition violent vomiting asserts itself. The 
ejected mass consists of the contents of the stomach — mucus, bile, 
and watery fluids, perhaps blood. Purging appears almost as early 
as the vomiting, and consists first of the normal contents of the 



ANTIMONY. 103 

intestines, then mucus, then bile, and, very rarely, blood. These 
signs may rapidly pass away and the characteristic " rice-water 
stools "* of antimonial poisoning appear. The general condition 
of the patient is now most serious. The face is pinched, livid, and 
covered with a cold sweat. The pulse is rapid and shuttle-like — to 
and fro — or lost at the wrist ; the arterial tension is almost nil. The 
respirations are faint and fluttering, and so shallow as hardly to be 
seen or heard. Cramps in the calves of the legs attack the patient, 
due to the abstraction of water from the tissues by the violent purging, 
and the temperature falls lower and lower as death approaches. The 
general condition is such that all the signs point to Asiatic cholera, 
and antimonial poisoning cannot be distinguished from this disease 
during an epidemic without a history of the case or a chemical analy- 
sis of the secretions, which ought always to be preserved. 2 

The treatment of antimonial poisoning consists in the internal 
administration of large amounts of tannic acid to form the insoluble 
tannate of antimony, in the use of the stomach-pump, and in the 
maintenance of an absolutely prone position. When tannic acid 
cannot be had, ordinary tea leaves may be boiled and the decoction 
given as an antidote and stimulant. The patient should vomit into 
towels and not raise the head from the pillow ; the head, indeed, 
should generally be placed lower than the heels. External heat, 
alcohol, and digitalis should be used freely, and opium should be 
employed hypodermically to allay pain and irritation unless the 
respirations are too feeble. If the opium is greatly needed because 
of pain, and yet seems contraindicated because of depression, it should 
be accompanied by strychnine to stimulate the respiratory centre and 
overcome any depression produced by the opium. 

Fatty degeneration of ail organs may occur as a result of acute anti- 
monial poisoning. 

Chronic poisoning by antimony is quite a rare affection, but it occurs 
chiefly in type-founders and type-setters. Mc Walter has reported 
instances in which . peripheral neuritis, disorders of the bladder, and 
irritability of the prostate developed in these artisans. Headache, 
abdominal tenderness, and an irritable state of the mucous membranes 
were also present, associated with profound mental depression and 
circulatory feebleness. These facts are of interest because it is a 
superstition among some of the lower classes that the administration 
of antimony will cure the alcoholic habit, and if given for a long time 
these symptoms and fatty degeneration might ensue, leading to a sus- 
picion of attempted murder by poison. 

1 A "rice-water stool" is one which, on standing in a glass, separates into two layers, 
the lower white and flocculent, the upper water and almost clear. 

2 This is a good opportunity to state that the secretions and excretions of a person 
dying of any poison should be placed in a chemically-clean jar capable of being sealed. 
The same rule of cleanliness applies to the jars holding organs at the post-mortem. 
The jars should be at hand, and no intermediate vessel used. They should be sealed 
at once, and kept so until claimed by the authorities. 



104 DRUGS. 



ANTIPYRINE. 



Antipyrine (Antipyrina, U. S. ; Phenazonum, B. P.) is a derivative 
of coal-tar, its chemical name being phenyldimethylpyrazolon. It 
was discovered by Lad wig Knorr in 1884, and introduced into medi- 
cine by Filehne. Antipyrine is a white powder of a somewhat bitter 
taste, and is very soluble in water, less so in ether, alcohol, and chlo- 
roform. 

When antipyrine is given to a man in full medicinal amount, it 
causes a sensation of buzzing and tightness of the head not unlike that 
produced by quinine. The bodily temperature, if normal, is depressed 
a fraction of a degree, but no other symptoms are manifested. If the 
dose be quite large, some blueness of the lips and finger nails appears, 
chilly sensations are experienced, and finally a profuse sweat breaks out 
over the entire body, which is more severe if fever has previously 
existed. Large doses sometimes cause nausea and vomiting. 

Physiological Action. — Nervous System. — When a large poison- 
ous dose of antipyrine is given to one of the lower animals, relaxa- 
tion, complete loss of reflex action, and total inability to move come on 
at once, and death ensues. Somewhat smaller doses produce exceed- 
ingly severe tetanic and epileptiform convulsions, but consciousness 
seems to be preserved. It has been proved that the chief cause of the 
convulsion is an action of the drug on the brain. 1 Very large toxic 
doses, therefore, decrease reflex action, and smaller ones increase it, 
though medicinal amounts certainly lessen reflex activity to a notable 
degree. The cause of this failure of reflexes is depression of the 
sensory nerves and the receptive centres of the spinal cord. Medi- 
cinal amounts must, therefore, be regarded as very distinct nervous 
sedatives, acting much more actively on the nerves of sensation than 
on those of motion. Injected beneath the skin or applied to a mucous 
membrane, antipyrine is a powerful local anaesthetic, the anaesthesia 
lasting often for several days. 

Circulation. — The studies of a very large number of pharma- 
cologists prove most conclusively that antipyrine in moderate doses 
has no effect on the circulation of the lower animals unless these be 
so frequently repeated that cumulative effects ensue. Many reliable 
clinical observers have asserted that the drug depresses the circula- 
tion in man in some cases, and antipyrine is certainly not a cardiac 
stimulant. The writer is confident, however, that antipyrine is not 
so distinctly a cardiac depressant as some believe. On the other 
hand, there can be no doubt that in some persons it tends to lower 
arterial tension and so to produce syncope. It must therefore be used 
with caution in cases which have a feeble circulation. Large, poison- 
ous doses lower blood-pressure unless convulsions are present, when 
the pressure is raised. In many of the cases where vascular depres- 
sion and collapse have followed its use it has been employed in exces- 

1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 



anTipyrine. 105 

sive amounts or the fall in bodily temperature has caused the unto- 
ward symptoms. (See Fever and its Treatment.) 

Blood. — No spectroscopic changes in the blood follow the use of 
medicinal doses of antipyrine in the ordinary individual, but in poi- 
sonous amounts it produces methsemoglobin. If the doses be toxic 
or idiosyncrasy exists, cyanosis may come on. That the blood is not 
destroyed by small amounts is proved by the absence of hsematin in 
the urine of persons taking the drug. The corpuscles suffer no 
changes except in very pronounced poisoning, when they are said to 
become crenated and shrivelled. 

Respiration. — When antipyrine is given in lethal doses, death 
results from failure of the respiratory centre. Ordinary doses have no 
effect on this function, but large ones make the breathing more rapid. 

Temperature. — In normal men and animals antipyrine in medi- 
cinal dose may be considered as without effect so far as bodily tem- 
perature is concerned. In fevered animals it has been found to lower 
temperature by decreasing heat-production and increasing heat-dis- 
sipation. That it does not do this by an action on the blood 
seems proved by the fact that the blood is not affected by medicinal 
amounts. The sweating does not cause the fall since it takes place 
when no sweating occurs. It may, therefore, be considered that the 
drug directly affects the nervous heat-mechanism of the body. 

Kidneys, Tissue- waste, and Urine. — A large number of studies 
made upon man and the lower animals by competent investigators 
have brought about very considerable advances in our knowledge of 
the influence of antipyrine upon tissue-waste. It is useless to burden 
this volume with a discussion of their methods and results, which 
may be found in the author's Essay on Antipyretics. Suffice it to say 
that, while all observers are not agreed as to the effects produced, the 
deductions apparently to be drawn are that the drug diminishes the 
quantity of the urine excreted, and also decreases the elimination of 
the results of nitrogenous tissue-metamorphosis — or, in other words, 
is a conservator of the tissues of the body. 

Elimination. — The elimination of antipyrine goes on very rapidly 
indeed, and begins almost at once after its ingestion. Maragliano 
and Reihlen state that it appears in the urine in three hours after it 
is taken, so that at the fourth hour elimination is at its height, 
although it continues to be eliminated for twenty-four or perhaps 
thirty-six hours. According to Pavlinow, part of the antipyrine 
ingested is eliminated by the salivary glands. 

Poisoning. — The treatment of poisoning by antipyrine consists in 
the administration of stimulants, the maintenance of bodily heat, the 
use of atropine to restore the tone of the vascular system, and, if 
cyanosis is alarming, the employment of oxygen inhalations. 

Antiseptic Power. — Antipyrine exerts a very distinct antiseptic 
action in small amounts, delays all forms of fermentation, and de- 
stroys germs when it is present in large quantity. 



106 DRUGS.' 

Therapeutics. — Antipyrine is employed in medicine for two great 
purposes — namely, for the reduction of fever and the relief of pain — 
but its employment as an antipyretic is now far surpassed by its use 
as an analgesic. 

As an antipyretic, antipyrine should be given in a few full doses 
rather than frequent small ones, as a general rule, since if the fever 
is of any severity the latter method of administering it will have no 
antipyretic effect, and the constant dosing will produce a gradual 
saturation of the system without causing a fall of temperature. On 
the other hand, too large doses may depress the temperature to a 
point below normal and induce collapse. In the article on Fevers 
(Part IV.) the conditions are indicated in which the drag is best em- 
ployed, these being the sthenic fevers as a rule, or instances where 
excessive outbursts of fever necessitate prompt reduction of tempera- 
ture. In excessively high temperature in pneumonia it has been used, 
and in scarlet fever and smallpox antipyrine is occasionally of service, 
although in pneumonia, as a rule, the condition of the patient indicates 
the use of cold to the chest as a local measure for the reduction of 
congestion or the use of cold sponging to relieve fever. (See Pneu- 
monia.) TIi e use of the cold applications is always to be preferred to 
antipyrine in the reduction of fever, since they are safer, more reliable, 
and do not strain the kidneys, reduce the blood, or depress the heart in 
feeble patients. (See Cold and Fever.) When cold water cannot be 
used, then antipyrine may be employed. In phthisis antipyrine gen- 
erally increases the sweating, produces oppression, and either fails to 
act as an antipyretic or causes collapse by exercising too great an effect. 
In sunstroke it frequently fails to influence the temperature, and 
ought not to be used. 

Be the fever what it may, provided it be associated with any dis- 
ease process, antipyrine is useless so far as any influence over the 
course of the disease itself is concerned. It is a remedy to be used 
in the treatment of the symptoms,, not for the removal of the cause of 
the fever. 

As an analgesic antipyrine is in some cases the peer of opium. 
Although the latter drug will relieve all forms of pain if it be pushed, 
it possesses many disadvantages not found in antipyrine. In deep- 
seated pains due to disease of the organs of the body, in inflammations 
and similar disturbances, antipyrine is useless. In neuralgic affec- 
tions of all kinds it finds its sphere, particularly if the disorder be 
rheumatic, gouty, or due to nervous depression from nervous exhaus- 
tion or disease. Under the latter circumstances it is best combined 
with caffeine and a little bromide of potassium. (See Neuralgia.) In 
acute rheumatism it will give relief in a fairly large number of cases, 
not only relieving the pain and fever if they be present, but also 
actually modifying the disease. It seems, however, to increase sweat- 
ing in acute articular rheumatism. In gout it is stated to have a 
specific curative effect upon the disease over and above the relief of 



ANTIPYRINE. 107 

the pain, but this is questionable. A useful remedy in gouty neuralgia 
and' muscular rheumatism is such a prescription as follows : 

Tfy — Antipyrinae gr. xxiv (1.6). 

Strontii salicylatis gr. xlviij (3.0). 

Elixiris aromatici f o ii j (90.0). — M. 

S. — Tablespoonful every hour for three doses in severe neuralgia, or three 
times a day for muscular rheumatism. 

Its use in dysmenorrhea has been recommended, but its beneficial in- 
fluence except in neuralgic cases is doubtful. At one time it was 
thought that its use would relieve the pains of labor, but this has, un- 
fortunately, proved untrue. It may, however, be tried, when suffering 
is very severe, in the dose of 15 grains (1.0). In the severe lanci- 
nating or darting pains of locomotor ataxia, and in the laryngeal 
and gastric crises complicating this disease, antipyrine is a valuable 
remedy. Curiously enough, it seems to subdue acute attacks of pain 
in posterior scla^osis, but it fails to control the slighter pains and mus- 
cular twitchings sometimes seen in this disease and in myelitis. 

Some clinicians have used antipyrine with asserted great success in 
diabetes mellitus. In such instances the disease often depends on a 
gouty diathesis, and can be as well relieved by salicylates. 

Antipyrine may be used hypodermically in the region of a hypersen- 
sitive nerve as a local anaesthetic. The anaesthesia produced by it lasts 
for several days, but the pain immediately after the injection is severe. 

Antipyrine is sometimes a very useful remedy in modifying the 
severity of epilepsy. (See Epilepsy.) 

In whooping-cough antipyrine has more frequently given relief in 
the writer's experience than any other remedy. It should be given 
to a child of five years in the dose of 2 grains (0.12) every four or 
five hours, the patient being watched for cyanosis and the drug stopped 
as soon as this symptom appears. Antipyrine generally decreases the 
frequency rather than the severity of the attacks of cough. 

In malarial diseases antipyrine certainly exercises no antiperiodic 
influence, although it controls the febrile paroxysms to a great extent. 
One cannot help thinking that frequently where antipyrine has been 
reported as acting as an antiperiodic it has simply lowered the fever, 
and so seemed to influence the disease. 

In acute coryza the temporary relief produced by applying cocaine 
to the engorged Schneideriau membrane may be prolonged very 
greatly by the use of a spray of antipyrine in the strength of 4 per 
cent. This produces a smarting sensation, which speedily passes away. 
The same treatment is of value in inflammations of the larynx and 
pharynx. Should cocaine solutions not precede the antipyrine, the 
primary irritant effects persist unless the strength of the solution of 
antipyrine is reduced to 1 or 2 per cent. It is always better to pre- 
cede its use by cocaine. 

Locally applied, antipyrine possesses very distinct haemostatic prop- 
erties, and for this purpose may be used in a 4 per cent, solution, either 



108 DRUGS. 

in liquid or in a spray. Under these circumstances it seems to act 
not by producing clots, which are disadvantageous from the stand- 
point of antisepsis, but by constringing the bleeding vessels. This 
haemostatic property is very materially increased if a solution of tan- 
nic acid is added to it, when it forms a glutinous precipitate which 
controls the hemorrhage. The precipitate is best applied by means of 
a swab. 

Autipyrine may be given with cocaine in suppository to check bleed- 
iug from hemorrhoids and relieve rectal paiu. The cocaine must be 
used to prevent the antipyriue from causing paiu when the suppository 
is first introduced. 

Untoward Effects. — Aside from the results of poisonous doses, a 
certain number of cases taking this drug present slight cyanosis or 
duskiness of the hands and of the face about the nose and lips ; the 
fiugers may be cold and clammy, and the feet are often very cold ; 
sweating is a very common symptom of the untoward influence of 
antipyrine, and pricking or tingling of the skin is not uncommonly 
seen. By far the largest number of these cases, however, suffer from 
disorders associated with the skin, and erythematous patches may be 
seen everywhere, more particularly on the hands and feet and about 
the face, arms, and chest. Occasionally pemphigus-like spots appear, 
and often large bullae have been noted as present. Elsewhere are 
published the statistics, collected from medical literature, of 121 cases 
of untoward effects exercised by antipyrine. 1 An analysis of these 
shows that females were much more frequently affected than males, 
and that the most susceptible age was decidedly that of full adult life 
— namely, from thirty to forty years in both sexes. The dose caus- 
ing these effects was most commonly a moderate one — from 10 to 15 
grains (0.60-1.0), or even from 4 to 10 grains (0.25-0.60). This 
fact holds good with regard to both sexes. The time of onset of the 
symptoms varied somewhat according to whether the drug was given 
in one excessive dose or in frequently-repeated medicinal doses. In 
many instances the appearance of the symptoms was sudden rather 
than gradual. As a rule, the duration of the symptoms did not 
exceed one to three hours, three days being the longest time men- 
tioned. It is interesting to note, however, that of all these cases only 
six proved fatal, and in these there was ample cause for death aside 
from any effect of the drug. We can rest assured, therefore, iu ordi- 
nary cases of disease that patients exhibiting untoward effects of anti- 
pyrine are not in any acute danger, although the symptoms may be 
temporarily most alarming. Typhoid fever seems according to the 
statistics collected by the writer, to be the disease in which this unex- 
pected influence manifests itself most frequently, but this may be due 
to the fact that it is so common a malady and is so frequently treated 
by means of antipyretics. Brunton is responsible for the statement 
that antipyrine is particularly prone to produce collapse in men- 

1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 



APIOL. 109 

struating women. Falck has collected a large number of cases of 
antipvrinism, and quotes Pusinelli as having seen vomiting often 
follow the use of this drug. 

Antipyrine very distinctly increases susceptibility of patients to 
taking cold, and ought not to be used by those who are forced to go 
out of doors in cold weather. 

Administration. — Owing to the solubility of antipyrine, it is most 
readily given in a little water in a wineglass or spoon. If its slight 
taste is disliked, it may be dissolved in any one of the aromatic waters 
or in syrup of bitter orange-peel or some similar vehicle. Most per- 
sons prefer to take it in tablet form. The amount which may be 
given at a dose is 5 to 20 grains (0.3-1.3), but 3 to 5 grains (0.20- 
0.3) is the best dose in most cases, at least until it is determined how 
it is borne. 

Incompatibles. — When added to sweet spirit of nitre, antipyrine in 
the course of a few moments produces a blue, changing to a dark- 
green, color, owing to the formation of iso-nitroso-antipyrine which 
is not poisonous, but which in the form of a dry powder is readily 
oxidized on exposure to slight heat. If this color is not formed, the 
spirit of nitre lacks its nitrous ether, and is worthless, so that we 
have not only another incompatibility to remember, but a new means 
of testing the therapeutic value of all samples of sweet spirit of nitre 
which may be dispensed. Antipyrine is also incompatible with the 
salts of iron, calomel, corrosive sublimate, and phenol. With salicy- 
late of sodium it forms a pasty mass; with chloral an oily liquid. 
Beta-naphtol and tannic acid are also incompatible with it, Tannic 
acid and non-alcoholic solutions of tannic acid form an insoluble 
precipitate with antipyrine as does also the tincture of iodine. 



ANTITOXIN 
(See Part III.) 

APIOL. 

Apiol is a camphoraceous body, derived from common parsley or 
Petroselinum, U. S. As its melting-point is very low, it cannot be 
kept in solid form, and is always dispensed in 75 per cent, solution. 
So far as is known to the author, no careful study of its physiological 
action has ever been made, but two French observers, Joret and 
Homolle, state that in overdose it causes ringing in the ears, intoxi- 
cation, and severe frontal headache. The official preparation is 
Oleoresina Petroselini, U. S., dose, 5 grains (0.3). 

Therapeutics. — Originally introduced to combat malarial fevers, 
because of a fancied resemblance in its toxic action to quinine, apiol 
has found its level as a remedy in amenorrlwa, given in the dose of 
2 to 8 minims (0.1-0.5) three times a day for a week before the 
expected date of menstruation. It should be given, if possible, 



110 



DRUGS. 



in capsules, owing to its unpleasant taste. It is said not to possess 
any abortifacient influence, although it is often taken with this 
object in view. 

Apiol is imported from France in capsules containing a little less 
than 3 minims (0.20), and is also put up in soft elastic capsules in 
the United States. 

APOCYNUM. 

Apocynam Cannabinum should not be confused with Apocynum 
Androsimcefolium, which has few of its properties, but which is 
often employed by mistake for the real drug. When good effects do 
not follow the use of the drug another sample should be tried. The 
remedy in overdose is capable of causing vomiting and purging 
through gastro-intestinal irritation,, but in medicinal dose rarely does 
so. It is employed in medicine for the relief of cardiac and renal 
dropsy of the subacute or chronic type, and is best given in the form 
of the tincture or fluidextract in the dose of 5 to 20 minims (0.30-1.3) 
of the former or 1 to 5 minims (0.05-0.30) of the latter. Under its 
influence profuse diuresis occurs, and the fluid is said to be removed 
so rapidly that the drug has been called the " vegetable trocar." 

Physiological studies show that the action of the drug on the heart 
is similar to that of digitalis, as it slows the pulse and raises blood- 
pressure. I have not obtained satisfactory effects from its use. 



Fig. 11. 



APOMORPHINE. 

Apomorphine is the hydrochloride [HCI.C17H17NO2] of an arti- 
ficial alkaloid, prepared from morphine by the abstraction of one 

molecule of water. It should 
be kept in small, well-stop- 
A pered vials, which have been 
previously rinsed with diluted 
hydrochloric acid and dried. 
It occurs as minute grayish- 
white monoclinic prisms, glis- 
tening, odorless, having a 
slightly bitter taste, and ac- 
quiring a greenish tint upon 
exposure to light and air. 

It is soluble in 50 parts of 
water, 50 parts of alcohol, 
1864 parts of ether, and in 
3800 parts of chloroform at 
25° C. (77° F.); soluble in 17 
parts of water at 80° C. 
(176° F.). It is obtained by 
the action of hydrochloric 
acid upon morphine in a sealed tube to which is applied a high heat. 
A very important point to remember is that its solutions rapidly 




A, apomorphine stimulates vomiting centre in the 
medulla. 



APOMORPHINE. HI 

decompose, and, if then employed, may produce poisonous symp- 
toms. The drug ought to be freshly dissolved each time it is used. 
If the salt imparts an emerald-green color to 100 parts of water when 
shaken a few times, it should be rejected, unless it is found that the 
water contains small amounts of ammonia, which is supposed to be 
active in causing such a change. 

According to Boyer and Guinard, there are two kinds of apomor- 
phine sold. Each has a physiological effect different from that of the 
other. The crystalline form, which is the one always to be employed, 
causes, in overdose, irritation, spasms, trismus, vertigo, and hyperes- 
thesia ; while the amorphous form (never to be used) causes collapse, 
hypothermia, general weakness, feebleness of the heart and respira- 
tion, and anaesthesia. 

Physiological Action. — One of the best studies of this drug is that 
of Reichert, who found that in poisonous doses it produces convul- 
sions, and finally paralysis, both of which are chiefly spinal in origin. 

Nervous System. — On the nervous centres in the brain apornor- 
phine acts as a sedative, but the convulsions produced by poisonous 
doses are probably spinal. The motor and seusory nerves are par- 
alyzed by poisonous doses, and even the muscles become poisoned 
and incapable of contraction. Medicinal doses have no effect. 

Circulation. — When given' in moderate amounts, apomorphine 
increases the rapidity and force of the pulse and raises arterial pres- 
sure by stimulation of the accelerator nerves and the vasomotor 
centre. In large doses it acts as a circulatory depressant. 

Respiration. — After ordinary amounts no changes in respiration 
occur, but after poisonous doses the breathing becomes rapid and 
irregular. 

Vomiting. — Vomiting is produced by a direct action of the drug 
upon the vomiting centre in the medulla, and not by an action on the 
stomach. Apomorphine is, therefore, a typical centric emetic. 

Therapeutics. — Apomorphine is useful in nearly all cases where an 
emetic may be employed. In poisoning from other drugs, particu- 
larly depressants and narcotics, we have little kuowledge of its safety. 
but unless the stupor or circulatory change is very profound, the drug 
may be used with care. Often a hysterical patient can be brought to 
herself by an apomorphine vomit. In subacute and chronic catarrh 
of the stomach and air-passages it may aid in getting rid of the mucus 
by emesis, and in non-emetic dose it is a useful remedy in acute bron- 
chitis when the secretion is very scanty. Non-emetic doses, given 
hypodermically, of -^ grain (0.002) have been used as often as every 
three hours with notable success in producing nervous quiet in alco- 
holic excitement and delirium tremens, and if combined with y^o 
grain of hyoscine it is particularly efficacious. 

Untoward Effects. — Apomorphine rarely causes disagreeable effects, 
but there are cases on record in which it has produced serious symp- 
toms even when given in ordinary doses. These symptoms have 



i 



112 DRUGS. 

consisted in depression and collapse. One-fifteenth grain is said 
to have caused death in a woman who had bronchitis, but was 
otherwise healthy„ Probably in these cases the amorphous form was 
used. 

Administration. — The drug when used as an emetic should always 
be given hypodermically and the solution be freshly prepared. The 
emetic dose is about T \ grain (0.006), but as much as \ grain (0.012) 
may be used in strong patients. The expectorant dose is ±\ to ^ 
grain (0.0015-0.003) by the mouth. No nausea is usually felt. The 
drug nearly always acts badly in children, and it is better not to use 
it in this class of patients. The salt used is Apomorphince Hydvo- 
chloridum, U. S. and B. P. An injection (Injectio Apomorphince 
Hypodermica) — 1 grain (0.06) dissolved in 110 minims (7.1) of dis- 
tilled water with 1 minim (0.06) of diluted hydrochloric acid — is 
official in the B. P. 

APOTHESINE. 

Apothesine is a local anaesthetic which is chemically the cinnamic 
ester of gamma-diethylamino-prophyl-alcohol hydrochloride. It 
appears in snow-w T hite crystals and is readily soluble in water, in 
alcohol, and slightly so in ether and acetone. It is said to be slightly 
less toxic to animals than novocaine and is used for exactly the same 
purposes, with or without adrenalin, for local and infiltration anaes- 
thesia and has proved generally efficient. It is placed on the market 
.in small hypodermic tablets. The strength employed is usually 
1 to 2 per cent, in salt solution. It can be sterilized by boiling. It 
does not produce a habit and does not come under the narcotic law. 

ARGYROL. 

Argyrol is a proprietary salt of silver, which is far less irritating 
than nitrate of silver, but is not so efficient as a germicide or anti- 
septic. It is important to use freshly prepared solutions. Its lack 
of irritating properties has, however, rendered it popular in a large 
number of conditions in which the nitrate of silver has hitherto been 
used. In cystitis 1 ounce of a 10 to 25 per cent, solution may be 
injected into the bladder and permitted to remain there some minutes 
before being passed or drawn off. When employed in gonorrhoea a 
16 per cent, solution may be injected four times in the twenty-four 
hours with advantage. To prevent or relieve ophthalmia neonatorum 
the strength of the solution should be 25 per cent. Stains caused by 
argyrol can be removed by the use of a 1 : 500 solution of corro- 
sive sublimate. 

ARISTOL. 

(See Thymol Iodide.) 



ARSENIC. 113 

ARNICA. 

Arnica (U. S.) is the dried flower heads of Arnica montana, a 
native plant of the Western United States and Europe. It holds a 
very high position in domestic medicine as a local and internal 
remedy in sprains and bruises, and in the treatment of passive hemor- 
rhages, amenorrhea, and similar states. 

Physiological Action. — When arnica is applied to a delicate skin, 
it produces burning and irritation, and even extensive skin lesions. 
According to the studies of the author, it slows the pulse, raises the 
blood-pressure slightly, and stimulates the vagus nerves. Toxic doses 
produce a rapid pulse from paralysis of these nerves. 

Administration. — Arnica is rarely given internally. If it is so 
used, the dose of the tincture of the flowers (Tinctura Arnicce, U. S.) 
is 15 to 30 minims (1.0-2.0), and the same amount of tincture of 
the root (Tinctura Arnicce Radicis) may be employed. The plaster 
(Emplastrum Arnicce) is useful in external applications. 

The tincture of arnica is the preparation usually applied to sprains 
and bruises, and the alcohol contained in this preparation accom- 
plishes a large part of the good achieved. 

The only British preparation is the tincture {Tinctura Arnica? 
florum), which is given in the dose of 30 minims to 1 drachm (2.0-4.0). 

ARSENIC. 

Arsenic (Arsenum) itself is never employed in medicine, but it is 
used in the form of arsenic trioxide (arsenous acid) or as the arsenate 
of sodium, arsenites of potassium, or of copper. When a physician 
speaks of giving arsenic to a patient he usually refers to arsenic 
trioxide. 

Arsenic trioxide (Arseni Trioxidum, U. S. ; Acidum Arseniosum, 
B. P.) is derived from arsenic-bearing ores by roasting them in a 
reverberatory furnace, when it rises in the form of a vapor which 
adheres to the walls of the furnace, requiring a second sublimation, 
owing to the first deposit being quite impure. It should contain not 
less than 99.8 per cent, of pure Arsenic Trioxide and occurs as a 
heavy solid occurring either as an opaque, white powder, or in irreg- 
ular masses of two varieties : one, amorphous, transparent, and color- 
less, like glass; the other, crystalline, opaque, and white, resembling 
porcelain. Frequently the same piece has an opaque, white, outer 
crust enclosing the glassy variety. Contact with moist air gradually 
changes the glassy into the white, opaque variety. Both are odorless 
and tasteless. 

In cold water both varieties dissolve very slowly, the degree of 
solubility varying according to conditions and time, the glassy variety 
requiring about 30, the porcelain-like or crystalline powder about 100 
parts of water at 25° C. (77° F.). Both "are slowly but completely 
soluble in 15 parts of boilipg water. In alcohol, Arsenic Trioxide 
8. 



114 DRUGS. 

is but sparingly soluble, but it is soluble in about 5 parts of glycerin. 
Oil of turpentine dissolves only the glassy variety. Both varieties 
are freely soluble in hydrochloric acid, and in solution of alkali 
hydroxides and carbonates. 

Physiological Action — The effects produced in man by poisonous 
doses will be found considered under the heading of Poisoning. 

Applied to the normal skin, arsenic trioxide produces no change of 
any moment, but if the surface be broken or a wound or sore exist, 
its action is very powerful, and it destroys the tissues to a consider- 
able extent. For this reason it has been employed as a caustic 
by " quacks " and to some extent by regular physicians, the latter 
using it to remove warts, condylomata, and similar growths, while the 
former have employed it chiefly as a " cancer cure/' asserting that it 
would take the disease " out by the roots/' which is, of course, untrue. 

Nervous System. — In medicinal amounts the drug probably acts 
as a stimulant to the trophic nervous apparatus. 

Circulation. — In moderate amounts arsenic has little or no influ- 
ence upon the circulation. Large doses cause marked decrease in the 
force and frequency of the pulse, accompanied by a decided fall in 
arterial pressure, and in these amounts it is to be regarded as a dis- 
tinct cardiac depressant which depresses all the heart's component 
parts, such as the ganglia, muscle, and nerves. The fall of the 
arterial pressure is due to vasomotor depression with relaxation of the 
general bloodvessels, more especially those of the abdominal cavity. 
According to Lesser, small doses act as a cardiac stimulant. Arsenic 
is absorbed by the bloodvessels and by a process of osmosis. 

Respiration. — In small amounts arsenic very distinctly stimu- 
lates the respiratory centre, and Lesser asserts that small doses stimu- 
late the peripheral ends of the vagi in the lungs, but that in toxic 
quantities arsenic acts as a powerful respiratory depressant. 

Absorption, Elimination, and Retention. — When arsenic in 
any of its soluble forms and in medicinal or moderately poisonous 
dose enters the body by way of the alimentary canal, or through a 
break in the skin, or by way of the lungs, it is speedily absorbed and 
distributed to all parts of the body by the blood and lymph. The 
rapidity of its absorption depends upon the activity of the circulation 
in the part with which it comes in contact, and when it is taken by 
the mouth upon the quality and quantity of the food and drink which 
may be present in the stomach. If these are considerable in amount, 
its absorption is of course delayed, as is also its local effect upon the 
mucous membrane. When brought in contact with the tissues in con- 
centrated form, it acts so powerfully that it may destroy them and so 
for a time at least prevent. its own absorption because the bloodvessels 
and lymph channels are prevented from carrying their normal fluids. 

When the dose is medicinal or slightly toxic, the drug is eliminated 
chiefly by the kidneys, although it escapes to some extent by all the 
secretions, such as the bile, the sweat, the saliva, and even in the milk 



ARSENIC. 115 

of nursing women, and it may produce in the nursling symptoms of 
gastro-intestinal irritation by this means. The rapidity with which 
it escapes from the body after it is absorbed varies greatly in differ- 
ent persons. It does not, as a rule, appear in the urine very promptly 
after it is taken, and it continues to be eliminated over a long period 
of time in some cases. Thus cases are on record in which it was 
found in this secretion several months after its use had been stopped. 

When a large poisonous dose of arsenic is taken by a human being, 
the greater part of it escapes from the body by reason of the vomit- 
ing and purging which it induces. It is possible for these efforts at 
elimination to be so prompt and complete that very little of the poi- 
son gains access to the general system. A large poisonous dose may 
therefore be less capable of producing death than one which is smaller 
in amount but nevertheless lethal in its effects. If the drug when 
taken in these poisonous doses is absorbed, it escapes, as it does in 
medicinal doses, chiefly by the kidneys, the feces, and by the other 
secretions named, and it is important to recall the fact that the 
amount of arsenic found in the feces does not represent alone that 
quantity which has passed through the alimentary canal unabsorbed, 
but also that it represents some of the poison which has entered the 
general system, because the liver and gastro-intestinal mucous mem- 
brane eliminate the drug by this pathway. 

During the time the arsenic remains in the body after absorption 
it is deposited chiefly in the liver and in the kidneys, in the walls of 
the stomach and bowels, and even in the muscles and bones. It has 
also been stated that it is deposited in the white matter of the brain 
in quantities which are considerable. When seeking for arsenic in a 
case of suspected death from this cause, it is important to examine the 
bones, because in some instances the drug is found in them in large 
amounts after it is no longer to be found in other organs. It is from 
these " storehouses " of arsenic that eliminating organs obtain their 
daily supply for elimination. Arsenic is so rapidly eliminated in some 
cases of fatal poisoning that only a trace of it can be found on chem- 
ical analysis after death. (See also Poisoning by Arsenic.) 

Tissue-waste. — According to Chittenden and Cummins, arsenic 
in medicinal amount distinctly decreases tissue-changes. Large doses, 
however, greatly increase nitrogenous metamorphosis. 

Therapeutics. — Arsenic is used in chorea, in which it is often most 
efficient, acting in an unknown manner. The dose should be increased 
rapidly, as patients soon get accustomed to the drug, and large doses 
are essential to produce a cure in most cases. Cases are on record, 
however, in which the continued use of large medicinal doses has 
developed arsenical neuritis or renal irritation. As a tonic combined 
with iron it is invaluable in simple ancemia, malarial anosmia, and 
cachexia. In atony of the mucous membrane of the stomach and 
intestine it is exceedingly useful, and in ordinary anaemia and debility, 
combined with a simple bitter tonic, it is invaluable. Arsenic is of 



116 



DRUGS. 



value, too, for the improvement of depraved mucous membranes of 
the respiratory tract, particularly in those persons who have not 
true tuberculosis, but phthisical tendencies; and in individuals who 
continually have colds in the head, chest, or elsewhere. Arsenic 
offers the best chance of benefiting cases of pernicious anosmia, but 

Fig. 12. 




A case of typical spleno-medullary leukaemia in which under the effects of arsenic the spleen 
decreased in size more than one-half, as shown in outline, and the white cells dropped from 342,000 
to 32,000. There was a gain in weight of twenty pounds. 



how it acts is not known. In leucocythcemia and pseudoleukemia 
arsenic is again the remedy, and it must be constantly given up to 
the point of intolerance to be of value (Figs. 12 and 13). In the latter 
disease good results have followed its use when intraglandular and 
intrasplenic injections of 4 minims (0.25) of Fowler's solution were 
used, and a case of severe ansemia, in which the stomach is disordered, 





5r r" 
2 — 

O 




CI 


5? _r 
ic -a co 




§5 1 


tc 


350,ooo 




















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330,000 
















325.000 
















32 1,000 
















315.000 


, 
















310.000 


\ 
















305,000 


\ 














300.000 


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280,000 


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275.000 


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15.00" 






Ww 




10.000 







Chart'showing the decrease in the number of the white blood-cells each time a patient suffer 
ing from spleno-medullary leukcemia received ascending doses of arsenic and hadrest in bed. 

(117) 



118 DRUGS. 

may be treated by giving by the rectum in starch-water three times 
the ordinary dose by the mouth or by its use hypodermically in the 
proportion of 4 parts of water to 1 of Fowler's solution. (See Sodium 
Cacodylate and Atoxyl.) 

In malaria arsenic acts as a prophylactic, as a cure, and as an aid to 
convalescence. When the attacks of intermittent fever occur at long 
intervals arsenic is useful as an antiperiodic, quinine being withheld 
for use during the attack itself. 

No drug is so universally abused as is arsenic in the treatment of 
skin diseases: it should never be employed in "wet" skin diseases; 
that is, those associated with much proliferation of new cells and the 
exudation of serum. Its field of usefulness is in the dry, scaly skin 
affections. 

When the skin is affected in its lower layers arsenic is useless, and 
should be used only when the epiderm is diseased (Duhring). 

In psoriasis arsenic at first makes the skin more red and seemingly 
worse, but this passes off and the patient gets well. This is impor- 
tant to remember, as otherwise the drug may be stopped just when 
doing good. Pemphigus, lichen, and lepra all yield to its influence in 
many instances. 

In the treatment of diabetes and pruritus vidva? the drug is said to 
be of value when given internally. In gouty diabetes the use of the 
carbonate of lithium and the arsenate of sodium is often of great 
service. 

In asthma, particularly when the mucous membranes are at fault, 
arsenic is one of the best remedies that we have, either given internally 
or smoked in arsenic cigarettes, which are to be made as follows : l 

R;— Belladonnae foliorum gr. xcvi. (6.4). 

Hyoscyami foliorum gr. xlv. (3.0). 

Stramonii foliorum gr. xlv. (3.0). 

Extracti opii gr. iv (0.25). 

Tabaci gr. lxxx (5.3). 

Aquse Oj. (480.0).— M. 

Fiat solutio et adde 

Potassii nitratis gr. clx (10.6). 

Potassii arsenitis gr. cccxx (21.3).— M. 

Bibulous paper is to be wetted with this compound, and after drying is to be 
rolled up and smoked as a cigarette. 

A more simple procedure is to wet bibulous paper in a solution of 
arsenite of potassium of the strength of 15 grains to the ounce, dry it, 
and smoke it in the form of a cigarette. 

In chronic rheumatism arsenic is a very valuable tonic in certain 
cases, but often fails to be of service. In chronic coryza, in cancrum 
oris, severe sore throat, and chronic nasal catarrh it is to be employed 
internally, and in some cases of hay fever undoubtedly affords relief. 
The use of arsenic in all stages of phthisis often gives the most 
surprising results. In gastric cancer and ulcer, given in small amounts 

1 Philadelphia Hospital Pharmacopoeia. 



ARSENIC. 119 

frequently repeated, arsenic will often do good by relieving the pain 
and checking the vomiting through its tonic influence on the gastric 
mucous membrane. It may be tried in the vomiting of pregnancy 
with some chance of success, and is often of value in the vomiting of 
hand-fed babies who are suffering from chronic gastric catarrh. It 
is also useful in the morning vomiting of drunkards. In atonic dys- 
pepsia associated with chronic diarrhoea and with a tendency to dys- 
entery arsenic trioxide is of service, and in small amounts it is very 
valuable in frequently repeated doses ( T Jo grain [0.0006] every hour) 
in all forms of serous diarrhoea. 

For gastric atony or torpidity the following prescription is useful, 
but if irritation of the stomach is present it should not be employed : 

T$ — Liquoris potassii arsenitis f5ss (2.0). 

Tincturae nucis vomicae f3j (4.0) vel f 3ij (8.0) 

Aquae q. s. ad. f5iij (90.0).— M. 

S.— Shake the bottle. Teaspoonful (4.0) t. i. d. in water after meals. 

F] — Arseni trioxidi gr. § (0.02). 

Ferri reducti gr. x (0.65). 

Extracti nucis vomicae . . . . . . . . gr. iv (0.24). — M. 

Fiant pilulse No. xx. 

S. — One t. i. d. after meals. 

In old persous whose feet become srcollen and hot after prolonged 
standing, and who have shortness of breath on exertion, arsenic does 
good, particularly if the cause be cardiac feebleness, when it increases 
the efficacy of digitalis or strychnine so greatly as to be generally indi- 
cated when these drugs are given. 

Locally applied to warts and other growths of the skin for several 
days in the form of Liquor Arsenicalis (B. P.) or Liquor Acidi 
Arsenosi (U. S.) or of Fowler's solution, it causes the growth to drop 
off or to become loosened. Where the growth is very hard and horny, 
its surface should be softened by the application of potassii hydroxidi 
before the arsenical liquor is applied. The same treatment may be 
used for corns. 

Where large malignant growths with extensive surfaces are to be 
attacked locally, the physician must use arsenic most boldly or not at 
all. The danger of absorption is only escaped when the drug is used 
so freely as to destroy the tissues before they can carry on any absorp- 
tion of the poison. A very large area should not be treated at one 
time. Marsden recommended the use of 1 ounce (30.0) each of 
arsenic trioxide and powdered gum acacia to 5 drachms (20.0) of 
water as an application to epitheliomatous growths. A less painful 
application because of the anaesthesia caused by orthoform, is as fol- 
lows: 

I*— Orthoformi 5j (4.0). 

Arseni trioxidi 5j (4.0). 

Alcoholis fgv (150.0). 

Aquae destillatae . fgv (150.0). 



120 DRUGS. 

Still another is : 

R — Arseni trioxidi gr. lxxv. (5.0). 

Pulveris acaciae gr. lxxv. (5.0). 

Cocainse hydrochloridi gr. xxx (2.0). 

Glycerini fflxxx (2.0) 

Aquae destillatae q. s. 

M. ft. paste. 

S. — Apply locally. 

The Marsden paste should be applied to the thickness of about 
one-quarter of an inch, overlapping the edges of the sore, and then 
covered with patent lint. The application is continued from twenty- 
four to forty-eight hours, and then a poultice is applied and the 
slough removed after from five to ten days. 

Administration. — Children generally bear arsenic better than adults, 
proportionately, but Ringer states that boys bear less than girls. The 
drug should be given before meals if it is designed to act on the 
stomach as a tonic, but in other conditions it should generally be 
administered after meals, as it is apt to irritate the stomach if given 
in full doses when this viscus is empty. Whenever a patient is given 
arsenic, he should be cautioned to watch for any puffiness about the 
eyes, particularly in the morning on arising, and for slight laxity and 
griping of the bowels. These are signs that the drug should be 
stopped for a day or more. The swelling under the eyes may spread 
if the use of the drug is persisted in, and finally amount to general 
anasarca. This is due at first to a cellulitis, and afterward to a true 
effusion. (See Untoward Effects.) 

It is important from a medicolegal point of view to bear in mind the 
fact that arsenic is one of those drugs to which it is possible to induce 
tolerance. That is to say, by the prolonged and gradual administration 
of arsenic in ascending doses individuals can finally take very large 
quantities with apparent impunity. Cases are recorded in which as 
much as 7 grains could be taken at one dose without any evil effects. 

The official preparations are : Arseni Trioxidum, U. S. ; Acidum 
Arseniosum, B. P., the dose of which is -jV to -^ grain (0.0015- 
0.003)— 6 V to T V grain (0.001-0.004) B. P. ; the solution of the 
arsenite of potassium {Liquor Potassil Arsenitis, U. S. ; Liquor Ar- 
senicalis, B. P.) or Fowler's solution, the dose of which at first is 
from 1 to 5 minims (0.06-0.3)— 2 to 8 minims (0.12-0.48), B. P.— in 
water ; the solution of arsenate of sodium (Liquor Sodii Arsenatis, U. S. 
and B. P.), or Pearson's solution, the dose of which is 1 to 5 minims 
(0.06-0.3)— 2 to 8 minims (0.12-0.48) B. P.— and the solution of 
arsenous acid (Liquor Acidi Arsenosi, IT. S.), the dose of which is 1 
to 5 minims (0.06-0.3). This is more irritating to the stomach than 
the other preparations. Arsenous iodide enters into Donovan's solu- 
tion (Liquor Arseni et Hydrargyri Lodidi, U. S. ; Liquor Arse7iii et 
Hydrargyri Lodidi, B. P.), the dose of which is 1 to 5 minims (0.06- 
0.30) — 5 to 20 minims (0.3-1.2), B. P. — given well diluted. Arsen- 
ous iodide ( Arseni Lodidum, U. S., Arsenii Lodidum, B. P.) is given in 



ARSENIC. 



121 



1 
Tiro 



to 2V g rain (0.0006-0.003)- 



2V to J grain (0.003-0.012), B. P.— 
doses, and arsenate of sodium (Sodii Arsenas, U. S. and B. P.) in 
the dose of y^ to ^ grain (0.003-0.0006)— & to T V grain (0.0015- 
0.006), B. P. — and the exsiccated sodium arsenate (Sodii Arsenas 
Exsiccatus, U. S.), dose ^wo to To g ram (0.0003-0.0015). Liquor 
Arsenici Hydrochlorides is also official in the B. P. 

Fig. 14. 




Herpetic eruption along the course of an intercostal nerve due to the use of 16 drops 
of Fowler's solution three times a day. 

Untoward Effects. — If arsenic is taken in full dose by a susceptible 
person, it may cause a marked dermatitis, with a sensation of severe 
burning in the skin and sometimes herpes zoster (Fig. 14). Pustulation 
may occur, and Falck asserts that an erysipelatous state may arise. 
Almost any form of skin lesion may follow its use internally or 
externally, but nearly all show irritation of the true skin. Even a 
scarlatiniform eruption followed by desquamation may ensue. In 



122 DRUGS. 

other cases the mucous membranes become inflamed and coryza may 
develop. (See Administration.) The prolonged use of arsenic, 
according to de Schweinitz, may produce vitreous opacities. 

Acute Poisoning. — The symptoms of acute poisoning by arsenic, 
that is, those following the ingestion of one or more large doses of the 
drug, are chiefly due to its irritating properties, but in part to the 
effects which it exercises upon the general system after it is absorbed. 
Usually within an hour after the poison is swallowed the patient 
experiences abdominal distress, a sense of constriction in the pharynx 
oesophagus, and in a short time suffers from violent abdominal pain 
with vomiting and later profuse serous diarrhoea. As soon as the 
bowel has been well emptied of its feces this diarrhoea becomes a 
symptom which is to some extent pathognomonic, that is to say, the 
stools become clear and may be like the so-called rice-water stools of 
cholera, containing flakes of mucous membrane floating in serum. 
These stools also appear in antimonial poisoning, but in arsenic they 
are often streaked with blood, whereas in antimonial poisoning blood 
is rarely if ever seen. The urinary flow is decreased, and it may be sup- 
pressed because of three factors: (a) the profuse purging drains the 
body of fluid; (b) the passage of the arsenic through the kidneys pro- 
duces an intense toxic nephritis ; (c) the vomiting prevents the inges- 
tion of water. If urine is secreted it is concentrated and albuminous. 

The general symptoms associated with those just described consist 
in pains in the extremities, probably due to the abstraction of fluid 
by the purging, great general depression and collapse, with increasing 
feebleness of the circulation and respiration, and finally death from 
the general intoxication produced by the drug, combined with exhaus- 
tion. As death approaches convulsions or coma may develop. Very 
commonly about the third day, if the patient survives so long, an in- 
termission in the symptoms appears, which will be followed by a re- 
turn of all the symptoms, so that the physician must not give a favor- 
able prognosis. In this symptom (remission) the course of arsenical 
poisoning resembles phosphorus poisoning and yellow fever. Death 
generally occurs about the fourth or sixth day, and on or about the 
third day a peculiar skin eruption sometimes appears which may be 
of any character. In rare cases sudden pain, collapse, and death may 
take place within twelve hours after the ingestion of the poison, or 
unconsciousness or heavy sleep, with entire absence of gastrointes- 
tinal symptoms ensues, death speedily coming on. Widespread mul- 
tiple neuritis may be developed if the case survives for several days. 

It is to be remembered that acute arsenical poisoning may resem- 
ble poisoning by any substance capable of producing intense gastro- 
intestinal irritation. The symptoms may also be closely allied to 
those of cholera morbus and Asiatic cholera, while in some patients 
the predominance of nervous twitchings and the coma may be con- 
fusing. 

After death from acute arsenical poisoning certain definite lesions 



ARSEXIC. 123 

are found, which are as follows: The mucous membrane of the stom- 
ach and bowel is reddened and inflamed, and it may be dotted by areas 
of hemorrhagic exudate. This is not due, however, solely to a corro- 
sive influence of the poison, for arsenic is not, strictly speaking, a 
corroding drug, as are the mineral acids, for example. The epithelial 
lining of the alimentary canal is easily slipped off as if corroded, but 
the actual lesion consists in the degenerative changes produced in it 
and the finer bloodvessels by the poison. Filehne has expressed 
the opinion that the epithelium is primarily devitalized by the arsenic 
and then softened and digested by the digestive juices. There is 
also present a severe diffuse toxic nephritis, and in the lower animals 
and perhaps in man marked changes in the suprarenal bodies. A 
typical change always present in acute poisoning when the patient 
lives for any length of time is fatty degeneration of all the viscera. 

The exact fatal dose of arsenic trioxide is unknown because the indi- 
vidual susceptibility and readiness of absorption vary greatly. It ia 
generally considered that from one and one-half to two and one-half 
grains is a lethal dose. Smaller amounts than this have, however, 
caused death and much larger ones have been survived. 

Only an infinitesimal amount of arsenic may be found on chemical 
analysis in toxic cases in the liver, bones, or nervous system. (See 
Salvarsan.) 

Treatment of Acute Poisoning. — In addition to washing out 
the stomach by the stomach-pump, applying external heat and stimu- 
lants, the ingestion of the proper antidotes should be at once employed, 
and the only ones of any value are the freshly precipitated hydrated 
sesquioxide of iron and magnesium oxide. (See below.) The first is 
to be prepared by the precipitation of iron from one of its fluid pre- 
parations by the use of an alkali. Ammonia added to the tincture 
of the chloride of iron is efficacious, but the precipitate has to be 
repeatedly washed to rid it of an excess of this irritant. Magnesia 
is a better precipitant, because it not only precipitates the iron, but is 
also an antidote itself. MonseTs solution and the so-called dialyzed 
iron may be employed in place of the tincture, but Mouse? s salt is too 
irritating. Dialyzed iron is so readily precipitated that it needs no 
alkali, but may be given pure. Magnesia is a useful antidote 
when given alone. Under the name Ferri Hydroxidum cum Mag- 
nesii Oxido the U. S. P. recognizes an antidote for arsenic ; this is 
often called the " antidotum arsenici." It is prepared as follows: 
Place 40 mils, of solution of ferric sulphate (Liquor Ferri Tersul- 
phatis, U. S.) with one hundred and twenty-five mils, of water, and 
keep the liquid in a large, well-stoppered bottle. Rub 10 grammes 
of Magnesium Oxide with cold water to a smooth and thin mixture, 
transfer this to a bottle capable of holding about one thousand mils., 
and fill it with water to about three-fourths of its capacity. When 
the preparation is wanted for use, shake the Magnesium Oxide 
mixture to a homogeneous, thin magma, add it gradually to the 



124 DRUGS. 

diluted Solution of Ferric Sulphate, and shake them together until a 
uniform, smooth mixture results. (See Iron, Hydroxide of.) 

After the use of the antidote emetics should be used, opium should 
be administered to allay irritation and pain, and large draughts of 
water be given to flush the kidneys and dilute the poison. In the 
later stages the danger from arsenical poisoning arises from the changes 
produced in vital organs. 

Subacute Poisoning. — When the dose of arsenic has not been large 
enough to produce death rapidly, the symptoms manifested are some- 
what modified. The vomiting and diarrhoea are less severe, but the 
abdominal tenderness and distress are notable. The kidneys are 
manifestly irritated by the drug, for the urine is scanty, bloody, or 
albuminous. In these cases sufficient time elapses for the secondary 
nervous lesions produced by the drug to result in outbreaks of Various 
eruptions on the skin and for localized palsies due to neuritis to ensue. 
(See Chronic Poisoning.) The mouth is parched, thirst is excessive, 
the liver is enlarged and tender, and the skin hot and dry. 

Chronic Poisoning. — Arsenic very frequently gains access to the body 
in many remarkable ways. It may be taken in cheap beers made 
from glucose, which in turn has been made with sulphuric acid pre- 
pared from iron pyrites contaminated by arsenic. In other instances 
it is obtained from wall-papers laden with arsenical pigments ; in still 
other instances it develops in artisans who handle arsenic in large 
amounts, and it is a curious fact that a common result in such 
persons is the development of a perforating but painless ulcer of the 
cartilaginous portion of the nasal septum. In rare instances the 
ingestion of a few large doses which usually produce acute poisoning 
has resulted in subacute or chronic poisoning because of slow absorp- 
tion and rapid elimination. Chronic poisoning may ensue by the 
drug entering by the mouth, lungs, or skin. 

The symptoms of chronic arsenical poisoning may for convenience 
be divided into three classes, although they are not so separated in the 
patient as a rule, being often interwoven in such a manner as to make 
a diagnosis difficult. In one class we find pigmentation of the skin, 
and nervous symptoms due to inflammations of the nerves, such as 
sharp attacks of pain, tingling in the extremities, patches of anaesthe- 
sia, and localized loss of motor power. Thus it not infrequently hap- 
pens that there develops paralysis of the extensor muscles of the toes 
or of the peroneal muscles. In other cases the flexors of the foot 
suffer chiefly, while in still others the feet escape and the hands are 
involved in the loss of power. In cases of acute poisoning the par- 
alysis may appear as early as the third day, while in other cases it 
may be delayed several weeks. The anaesthetic areas are generally 
confined to the extremities, and extend only to the first or the second 
joint above. Sometimes the multiple neuritis caused by arsenic gives 
rise to symptoms which resemble those of locomotor ataxia. 



ARSPHENAMINE. 125 

In other cases the manifestations of irritation of the mucous mem- 
branes are the predominant symptoms associated with disturbances in 
the nutrition of the skin, so that eruptions are produced, with falling 
of the hair and the development of cachexia. When the poison is in- 
haled, violent attacks of coryza or of asthma may occur and chronic 
bronchitis ensue. 

Chronic arsenical poisoning must be differentiated from chronic 
lead poisoning and chronic alcoholism. All three of these states may 
occur simultaneously. From lead poisoning it is to be separated 
by the absence of the blue lines on the gums, by the fact that in plumb- 
ism there is rarely much disturbance of sensation and that the motor 
palsy of lead commonly affects the extensors of the forearm rather 
than the muscles of the leg, as does arsenic. The history of the 
patient is also of great aid in the differentiation. It is also said to be 
a fact that muscular atrophy is more rapid in its progress in arsenic 
intoxication than in that due to lead. In lead poisoning eruptions and 
discolo rations of the skin are rare. 

Alcoholic neuritis is to be differentiated from arsenical poisoning by 
the history and appearance of the patient, by the absence of disorders 
in the skin, and by the presence of mental deterioration. 

Chronic poisoning is to be treated by withdrawal from the exposure 
and by the use of iodide of potassium to aid in the elimination of the 
arsenic. The special symptoms are to be treated by the application 
of electricity, tonics, out-of-door life, and such measures as will im- 
prove the general condition of the patient. 

(See Atoxyl and Arsphen amine.) 

ARSPHENAMINE. 1 

Arsphenamine, sometimes called "606" or, more correctly, dioxy- 
diamido-arsenobenzol dihydrochloride, is a fine yellow powder, 
readily soluble in water, methyl alcohol (1-3), and in glycerin, but 
less soluble in ethyl alcohol, and is insoluble in ether. It depends 
chiefly for its therapeutic power upon its content of arsenic. Owing 
to the fact that it is readily oxidizable it is kept in small ampoules 
in a vacuum. For this reason the contents of an ampoule when 
opened should be used at once, and none of the drug saved for another 
dose, as any change in its composition makes it poisonous. (See 
Neo-ar sphenamine . ) 

Physiological Action. — Salvarsan when first introduced was supposed 
to act by reason of the fact that it combined with and destroyed the 
protoplasm of certain parasites found in the blood and tissues without 
damaging the protoplasm of their host, destroying the Treponema 
pallida, the spirillum of relapsing fever, and the Trypanosomes of 
sleeping-sickness. Ehrlich now believes that its action is indirect and 
is of the nature of complement-fixation reaction, for salvarsan does 
not destroy the spirochete in vitro but only in vivo. (See p. 28.) 

1 Arsphenamine is the name of the American product whereby use of the German 
product called salvarsan is avoided. 



126 DRUGS. 

Elimination. — Salvarsan is broken up in the body and eliminated 
as arsenic. When given intravenously most of the arsenic may 
be recovered from the urine within twenty-four hours, but some of 
it is retained for many days. Jesionek found it in the urine during 
the fourth week after an intravenous dose of only 0.4 Gm. The 
eliminative process is even more slow when it is used intramuscu- 
larly. Its slow elimination may possess great medicolegal impor- 
tance in toxicological cases. Jeanselme, Yernes, Butrand, and Bloch 
in a joint report state that the arsenic is chiefly found in the liver, 
spleen, the lungs, and the kidneys. 

Therapeutics. — The chief use of salvarsan is the treatment of syphilis 
in all its stages, but particularly the acute form, as represented by 
mucous patches, skin affections, and the chancre. When the disease 
has existed long enough to result in the destruction of tissue, salvarsan 
cannot be expected to cause the regeneration of tissue which is 
destroyed. 

Salvarsan may be said to have the following scope of usefulness and 
limitations : 

1. Salvarsan is not to be resorted to in haphazard manner, as we 
are using a tool with a very sharp edge. In the presence of severe, 
fulminating syphilis in an acute form it should always be used, barring 
extraordinary contraindications. 

2. It is to be recalled that inadequate doses of salvarsan not only 
fail to cure the disease but also produce a strain or breed of spirochetes 
which are so immune to its affects that large doses given later may also 
fail. 

3. Given within two weeks of the initial lesion it may, if given in 
repeated doses, produce a complete cure so far as we at present know, 
although years must pass before this is determined. 

4. Given to a patient with active lesions on the penis, or elsewhere as 
the point of infection, and mucous patches in the mouth, it exerts a 
marvellous influence, so that these lesions speedily become sterile, 
sometimes after one dose, and often heal promptly. Its power to 
produce a true cure diminishes as each week goes by, and after second- 
ary symptoms are well established it fails unless associated with mer- 
curial injections. This is proved by the frequent recurrence of relapses, 
particularly in nervous syphilis (see No. 6) and in cases of gumma. In 
other words, salvarsan relieves the symptoms of syphilis, but does not 
always eradicate the infection and the aid offered by mercury is 
essential. 

5. The mild lesions in the skin in the secondary stage are affected 
apparently no better by salvarsan than by mercury skilfully used, but 
severe ulcerative lesions are affected better by the new drug than the 
old. 

6. Gummatous lesions of the skin yield better than with mer- 
cury, but gummata of internal organs are equally well affected by 
mercury. 



ARSPHENAMINE. 127 

7. In the cases in which syphilis of the nervous system is present 
it often fails, not only because degenerative changes have occurred 
which cannot be repaired, but also because it has been found that sal- 
varsan when in the blood cannot enter the cerebrospinal fluid in any 
quantity, since the tissues do not seem permeable to it, that is," the 
cells which secrete the fluid will not allow such complex molecules to 
pass through them. It has been found that relapses occur in late ner- 
vous syphilis treated by salvarsan more frequently than when treated 
by mercury, and that nervous symptoms may become accentuated by 
its use, probably by development of a Herxheimer reaction. 

8. A course of salvarsan injections should be followed by a careful 
course of mercury in the form of gray oil or the protiodide, since 
there is no doubt that mercury does good in syphilis that salvarsan 
cannot do. (See Mercury.) 

9. Given to a syphilitic mother it produces antibodies in the blood 
and milk, whereby a favorable effect can be produced in a nursing 
infant suffering from syphilis. 

10. Salvarsan seems to be even more of a specific in yaws, trypano- 
somiasis, and relapsing fever than in syphilis. It is also useful in 
malaria. (See Cinchona.) 

11. The so-called Wassermann reaction disappears under the influ- 
ence of salvarsan, but when a patient with a history of syphilitic 
infection of long standing gives a negative Wassermann reaction it 
is sometimes possible to produce a positive reaction by giving a series 
of small doses, that is, the drug may be used as a diagnostic agent. 
This is called "provocative dosage." It is not to be forgotten that a 
positive reaction from a provocative dose may not appear for from 
two to seven days. 

12. Brocq well says : "Whatever be the power of the new arms which 
have lately been placed at our disposal for the treatment of pox, the 
practitioner must clearly understand that the old rules of therapeusis 
have not undergone any change. He must grasp the idea that his 
duty is first and foremost to place the organism in the best possible 
state to resist and thus minimize the virulence of the infection; that by 
a well-ordained hygiene he may reduce to a minimum the secondary 
manifestations and the tertiary liabilities." 

When syphilitic symptoms are urgent and no contraindications are 
present (see page 132) Ehrlich advises 0.6 gramme doses given intra- 
venously at intervals of four days, but the intravenous dose varies 
with the character of the disease, the general health, the age, and sex. 
In nervous diseases due to syphilis Ehrlich states the average dose to 
be 0.2 gramme (3 grains) as a maximum. In ordinary primary syphilis, 
particularly if it be severe, the maximum dose should be 0.5 to 0.6 
gramme (6-10 grains). Women usually receive 4 to 0.5 gramme (4- 
7 grains); children, 0.2 to 0.3 gramme (3-5 grains). So, too, a feeble 
patient should not receive more than the dose for a child. When the 
dose is repeated it is rarely given until eight days have elapsed, and 



128 DRUGS. 

often not for two weeks, but in rare cases it may be used every other 
day. If the reaction due to the destruction of the parasite is severe, the 
second dose should be postponed or, if this is inadvisable, it should be 
smaller. When the disease is severe or persistent, six to eight doses are 
to be given within two or three months. Afterwards 6 to 8 intramuscu- 
lar injections of salicylate of mercury given at intervals of one week 
are advisable. This double treatment is to be resorted to two or three 
times at intervals of three months. Three or four good-sized doses 
in the presence of active secondary symptoms, followed by mercury, 
may suffice; but this is rarely true, and what seems to be a cure of the 
disease results in latent syphilis which ultimately wrecks the cardio- 
vascular-renal tissues or manifests itself in the nervous system. Warthin, 
writing as a pathologist, emphasizes these points in these words: 

" The therapeutic lesson is evident. Promises of cure within definite 
time-limits can never be safely made, and our advice as to treatment 
must include the possibility of treatment extended over many years. 
The syphilitic must be treated as a germ carrier. The latency of the 
infection seems to be the same in many untreated cases as in those 
receiving very good treatment. Our present-day treatment seems 
only to succeed in rendering the infection latent rather than in curing 
it. Clinical cures may not be cures at all, as shown by the autopsy." 
For these reasons the physician should always keep up the treatment 
until the Wassermann test of the blood is negative. At the end of a 
year if the blood is still negative a small so-called "provocative dose" 
is to be given. If the Wassermann is still negative the spinal fluid 
should be tested and if it is negative then the luetin test should be 
used; when if this is also negative the patient may be considered 
really cured. 

If the symptoms are more advanced, as in tertiary syphilis with a 
positive Wassermann or luetin test, treatment must be continued for 
a long time with mercury. (See Mercury.) 

To attack the parasite in the cerebrospinal fluid or tissues Swift and 
Ellis and, since then, many others, have given salvarsan in the usual 
way, then drawn some of the blood from the patient's vein and injected 
the serum containing minute amounts of the drug and the newly formed 
antibodies into the spinal fluid by spinal puncture, thereby avoiding 
the danger which would be present if salvarsan was directly injected 
by this route. When cerebrospinal syphilis is present it would, there- 
fore, seem good practice, particularly in locomotor ataxia and paresis, to 
give an intravenous dose of salvarsan or neosalvarsan. An hour later 
about 40 mils, of blood are taken from the arm, allowed to coagulate, 
and centrifugalized. The next day 12 mils, of the serum are diluted 
with 16 mils, of normal saline solution and heated to 56° C. for half 
an hour, since this heating has been found to increase its parasit- 
icidal properties. Lumbar puncture is now performed and cere- 
brospinal fluid withdrawn until the manometer shows the pressure 
to be about 30 mm. of mercury. The barrel of a good-sized syringe is 



ARSPHENAMINE. 129 

attached to the needle, which has been left in situ, by means of 40 cm. 
of rubber tubing, and the tubing is allowed to fill with cerebrospinal 
fluid up to the syringe, thereby driving out all air. When the tube 
is filled up to the barrel of the syringe the barrel is filled with the 
serum already prepared, and by slowly and gently elevating the tube 
and barrel the fluid enters the subarachnoid space. The dose of sal- 
varsan is usually 0.45 to 0.5 every two weeks until the Wassermann 
test when applied to the spinal fluid is negative. In certain cases of 
locomotor ataxia this injection may cause some pain in the legs, which 
is easily relieved by codeine or morphine. Too much cannot be ex- 
pected from this plan, for destroyed tissues cannot be renewed. When 
the spirochete are living in the cerebrospinal tissues great improve- 
ment may ensue from this treatment in the early stages of tabes, but 
to a much less degree in paresis. When evidence of infection of the 
brain or its membranes is marked it is best to precede this treatment 
by active mercurial medication, since by this means the danger of 
Herxhehner's reaction is decreased. (See Untoward Effects.) It is 
not sufficient to rely upon the Wassermann reaction in the blood, as 
it may be negative at a time when the cerebrospinal fluid will give a 
positive reaction. Furthermore, the Wassermann test of this fluid 
may be negative yet the colloidal gold test may be positive. 

When Ehrlich first introduced salvarsan his idea was to give one 
large dose to destroy the spirochete at one stroke, because it was 
feared that the micro-organism might become resistant to the drug if 
exposed to its moderate effects gradually. Ehrlich's view has been 
found to be erroneous, although it holds true with sufficient force to 
make it inadvisable to give very small doses over long periods of time. 

Administration. — Salvarsan, may be given intramuscularly, subcu- 
taneously, or intravenously. The subcutaneous method has been 
practically discarded. Given intramuscularly, the remedy may cause 
pain and may produce inflammation and sloughing, although this 
rarely occurs. It acts more slowly given in this way, but is less prone 
to cause sharp and severe general effects than if given intravenously. 
Different clinicians favor each plan and also advise various ways of 
preparing the drug for use, but in the majority of cases the intravenous 
method is the one of choice. In the preparation of the drug for use it 
must be borne in mind that salvarsan is a dihydrochloride of dioxydi- 
amidoarsenobenzol, and that when it is dissolved in water it forms a 
diacid solution. When so dissolved with the addition of one molecular 
proportion of sodium hydroxide, it forms a mono-acid solution. If it is 
dissolved in water with two molecular proportions of sodium hydroxide, 
it makes a neutral suspension of the free base. If three molecular pro- 
portions of sodium hydroxide are added it forms an alkaline solution, 
not a suspension. All of these forms have been used. The alkaline 
solution is most commonly employed. The following table may be 
used to indicate the proportions of salvarsan and sodium hydroxide in 
15 per cent, solution used for intravenous or intramuscular use. 
9 



130 



DRUGS. 



Salvarsan. 



Official 15 per cent, sodium hydroxide. 



gramme. gramme. 

0.6 1.308 

0.5 1.09 

0.4 0.872 

0.3 0.654 

0.2 0.436 



mils. 


corresponding to drops 


1.14 


" 23 


0.95 


u 19 


0.76 


" 15 


0.57 


" 12 


0.38 


" 8 



Into a glass cylinder of 500 mils, capacity, with a ground-glass 
stopper, put from 30 to 40 mils, of sterile normal salt solution (for 
caution see Intravenous Injection, Part III), and add 0.6 gramme of 
salvarsan. Shake thoroughly until dissolved, and add about 1 .14 mils. 



Fig. 15. 




Apparatus for intravenous injection of salvarsan. 

(23 drops) of 15 per cent, sodium hydroxide solution. This forms a 
precipitate that redissolves on vigorous shaking. Add enough normal 
saline solution to make 300 mils., adding a few drops of sodium 
hydroxide solution, if need be, to keep the solution intact. Each 50 
mils, of this contains 0.1 gramme of salvarsan. This is for intravenous 
use. 

For intravenous injection a syringe may be used, but an apparatus 
such as is commonly employed for the intravenous injection of normal 
salt solution is much better. (See Fig. 15.) The injection should be 
given very slowly over a period of eight minutes, while the patient is 
lying down, through a large hollow needle (No. 16 or 18) or a small 



ARSPHENAMINE. 131 

canula, which is pushed into a vein. Care must be taken that the 
fluid does not escape into the perivenous tissues, as it will cause great 
pain. To avoid such an accident it is best to run in some plain normal 
saline solution first, so as to be sure the needle is in the vein, and, in 
order that none of the salvarsan may remain in the vein when the 
injection is finished, it should be followed by a little saline solution. 

A number of material modifications of this plan have been introduced 
designed to simplify the technique. Thus 0.6 gramme of salvarsan is 
placed in 10 mils, of sterile distilled water, then shake the mixture 
vigorously until complete solution takes place. When solution is 
absolute, add 19 drops of the 15 per cent, sodium hydroxide solution 
which causes precipitation which redissolves on shaking. Enough 
sterile distilled water is now added to make up 15 mils. If the solu- 
tion is not clear add one more drop of sodium hydroxide and shake 
well. If after three minutes the solution is not complete repeat this 
procedure. Now draw the solution into a 20-mil. Luer syringe. Insert 
needle into vein so that the appearance of blood proves that the vessel 
has been entered, expel all air from the syringe and inject slowly over a 
period of several minutes. This method permits the use of syringe 
and avoids the ill effects sometimes induced by large injections. 

Before salvarsan is used by the intravenous route the patient 
should have the bowels well purged and have an empty stomach. 
He should be lying down when it is given. 

After all injections the patient should remain recumbent for several 
hours, and before the injection is given the skin at the site of operation 
should be sterilized by 2 per cent, tincture of iodine. 

Another method, involving the use of almond oil, olive oil, or liquid 
petrolatum, permits the injection to be given intramuscularly. Place 
a small amount of sterilized liquid petrolatum in a clean, dry and cool 
mortar and add the salvarsan to it gradually, with active trituration 
with a pestle, so that the resulting mass is perfectly smooth. This 
mixture when of the proper consistency to permit its use is drawn up 
into a strong syringe, the barrel of which must be first wiped dry and 
oiled. Care must be taken that none of the drug is left in the wound 
made by the needle, as it may cause a slough. This can be avoided 
by injecting deeply and being sure that the needle is well emptied by 
an energetic push at the end of the injection. 

If possible the physician should use the sterile sealed ampoules now 
placed on the market containing salvarsan suspended in fat instead 
of attempting to use the plan just given. For intramuscular injection 
a strong glass syringe and a strong needle of No. 20 gauge should be 
used. The area for an intramuscular injection should be 2 inches 
outward from the union of the folds of the buttocks (see Salicylate of 
Mercury). Intravenous medication is, however, almost universally 
resorted to. 

Untoward Effects. — Aside from severe pain, chills, or sick stomach 
which sometimes ensue after the injection of salvarsan, suppression 



132 DRUGS. 

of urine and even death has followed its use, but these accidents have 
been usually in cases suffering from renal disease. Sometimes these 
symptoms are due to the use of water which has not been distilled 
just before it is used. In other cases it is due to the drug. When it 
develops after the second, or later, doses are given it seems to be a 
species of anaphylaxis. (See Antitoxin.) In these cases the symptoms 
are respiratory, cardiac, and of a suffocative type. Should pallor, chill, 
or emesis occur, the injection must cease. There may be for a time 
marked reddening and congestion of the local lesions, and under the 
term " Herxheimer's reaction" is described an increase, or darkening, 
of the syphilitic eruption in the first twelve hours after the injection. 

Sometimes two to four days after an injection there develops dizzi- 
ness, deafness, and a stuporous state which in nervous syphilis may 
amount to unconsciousness. These symptoms may be considered a 
form of Herxheimer's reaction in that the destruction of the parasites 
sets free their toxic content and this in turn causes irritation and pos- 
sibly swelling of the nervous tissues. In others these symptoms develop 
at once after a second injection. Ehrlich has pointed out that to repeat 
the dose within four or five days in such instances is equivalent to 
pouring oil on a fire and may cause the death of the patient, and if a 
marked dermatitis develops Fordyce insists that it is very dangerous 
to repeat the dose within six months or a year. In those cases in which 
severe symptoms develop in a few hours after a dose and consist of 
meningeal irritation, jaundice, or evidence of renal inadequacy or 
inflammation, the patient is probably suffering from arsenical poison- 
ing because he has an undue susceptibility to arsenical preparations. 
Ehrlich believes that in delayed toxic cases the symptoms may be due 
to an oxidation product of salvarsan, paraminophenylarsenoxide. In 
other instances it is due to a deficient secretion of adrenalin. He ad- 
vises that large doses of this substance be given hypodermically when 
diarrhoea, suppression of urine, cyanosis, or coma follow the use of 
salvarsan and asserts that adrenalin will save desperately ill patients. 

Contraindications. — Salvarsan is contraindicated in advanced degen- 
erative lesions of the nervous system or kidneys, in advanced tuber- 
culosis, when there is disease of the nervous portion of the auditory 
apparatus, and in persons who have a marked idiosyncrasy to arsenic. 

Salvarsan must be used with the greatest caution, or riot at all, in 
the presence of marked myocarditis. So, too, in acute cerebral syph- 
ilis it must be used with care lest it produce an acute exacerbation by 
intensifying the inflammatory process already present. Such cases 
should first receive a thorough course of mercury and iodides. (See 
Untoward Effects.) Addison's disease contraindicates this drug, as 
does also status lymphaticus. 

Under the name of salvarsan natrium or sodium salvarsan, Ehrlich 
shortly before his death introduced a preparation 1206 A. It contains 
the same amount of arsenic as neosalvarsan (20 per cent.) and is 



ASPID1UM. 133 

very soluble in water. It is claimed to be atoxic but is too irritating 
for subcutaneous use. As it is comparatively less toxic it is not so 
definitely contraindicated as salvarsan or neosalvarsan in renal dis- 
ease. The intravenous dose varies from 0.3 to 0.45 at the same 
intervals as salvarsan is given. It is usually given in a 0.4 per cent, 
salt solution in the proportion of 0.1 gramme to 10 mils. 

ASAFCETIDA. 

Asafoetida, U. S., Asafetida, B. P., is a gum resin obtained by making 
an incision into the root of Ferula fcetida. It occurs in irregular 
masses of a dark-yellow or reddish color, which become still more red 
if exposed to the light and air. Asafoetida in tears is a term applied to 
the drug when it appears in the shape of drops or pearls, and is a form 
seldom seen. Its odor is penetrating and strong, and resembles that 
of garlic. When taken internally, it causes a sensation of warmth and 
acts as a stimulant and carminative in the alimentary canal. 

Therapeutics — Asafcetida is used in medicine as a carmincdive 
which will particularly affect the lower bowel, and is useful in the 
intestinal indigestion of old persons when associated with flatulence, and 
in the flatulent colic of children. In the form of rectal injections it is 
of value for relief of the tympanites of children and in that of adults dur- 
ing typhoid, fever and pneumonia. It is also used as a stimulating ex- 
pectorant in the later stages of bronchitis. In the nervous irritability 
of children it is often of service. 

Administration. — Asafoetida is given in pills of asafoetida (Pilulte 
Asafodidce, U. S.), of which two or three maybe taken, each one 
containing 3 grains (0.20); the emulsion or milk of asafoetida (Emulsum 
Asafcetidce, U. S.), the dose of which is J to 1 ounce (16.0-30.0); 
and the tincture (Tinctura Asafcetidce, U. S. and B. P.), J- to 1 fluid- 
drachm (2.0-4.0). The suppositories at one time official contained 
the equivalent of 40 drops (2.6) of the tincture. The plaster of asa- 
fcetida (Emplastrinn Asafcetidce) is used where a mild counterirritant 
and antispasmodic is needed. When intestinal indigestion and 
flatulence occur in old people, the following pill is of service: 

1$ — Extracti nucis vomicae gr. v (0.3). 

Pulveris capsici gr. xx (1.3). 

Asafoetida? gr. xl (2.6). — M.' 

Fiant pilulae No. xx. 

S. — One night and morning. 

A B. P. preparation, not official in the U. S. P., is Pilula Galbani 
Composita, composed of asafoetida, galbanum, and myrrh; dose 4 to 
8 grains (0.24-0.48). 

ASPIDIUM. 

Aspidium, U. S., Filix-mas, B. P., or Male Fern, the rhizome of 
Dryopteris Marginalis (or Aspidium Filix-mas, B. P.) is employed in 
medicine as a tseniacide or remedy for the tape-worm, and is a very 



134 DRUGS. 

efficient and valuable drug under such circumstances, being, perhaps, 
the most reliable of all the taeniafuges except pelletierin. When 
employed, the directions and precautions given in the article on Worms 
must be strictly followed (Part TV.). It is also a valuable remedy 
in uncinariasis. 

Male fern taken in overdose is capable of producing poisoning, and 
when taken in such a dose causes, according to Quivill, irritation and 
the gastro-intestiual mucous membrane and diarrhoea. If absorbed, it 
acts on the central nervous system and causes paralysis, collapse, and 
death. The form and method by which it is eliminated are unknown. 

It may in overdose cause albuminuria and glycosuria. To give 
more than 1 J drachms (6.0) of the oleoresin at a dose is dangerous. 

Administration. — Male fern is rarely, if ever, used at present in its 
crude form, being employed most commonly in the United States in 
the form of the oleoresin (Oleoresina Aspidii, U. S.) ; dose J to 1 
fluidrachm (2.0-4.0) in capsule, or as follows : 

R — Oleoresinae aspidii, 

Tincturae vanillae aa TTlxlv (3.0.) 

Pulveris acaciae 5ss (2.0). 

Aquae destillatae f^j (30.0).— M. 

S. . Take entire amount after fasting, and follow in two hours by a full dose of 
sulphate of magnesium. 

Another useful formula is as follows : 

1^ — Oleoresinae aspidii f 3hj (12.0). 

Fluidextracti kamalae f3ij (8.0). 

Chloroformi V([x (0.65). 

Olei tiglii TTLJ (0.06). 

Olei ricini q. s. adfgij (60.0).— M. 

S. — After a purgation with calomel and a saline purge give one-half of this, 
and give the second half two hours later. 

The dose of the liquid extract (Extractum Filicis Liquidum) of the 
B. P. is 45 to 90 minims (2.7-5.4). 

Katamaya and Okamoto, two Japanese investigators, and Poulssen, 
state that castor and other oils should not be used after filix-mas is 
given, as oils increase the absorption of the active principle, and so 
predispose to the development of poisoning. 

ASPIRIN. 

Aspirin is acetyl-salicylic acid (Acidum Acetylsalicylicum, B. P.), 
and occurs in white crystalline needles which melt at 135° C. and 
is soluble in 300 parts of water. It is readily dissolved in alkaline 
fluids. Owing to its chemical constitution, aspirin has been intro- 
duced into medicine as a substitute for the ordinary salicylates; 
and as it is dissolved and absorbed in the bowel, as is salol, it is said 
not to irritate the stomach. Unless well diluted, however, it causes 
gastric distress. It is not so disagreeable to the taste as are most 
of the salicylate preparations, and it is claimed is less likely to cause 



ATOXYL. 135 

tinnitus. The dose of aspirin as a remedy for acute rheumatism is 
10 to 15 grains (0.6-1.0) four times a day or oftener. It is also used 
in lithremic or gouty states in place of the older salicylates. It may 
also be employed as an intestinal antiseptic. Its most general use, 
however, is for the relief of neuralgic pain. Aspirin may be applied, 
by means of dipping an applicator covered with wet cotton in the 
finely powdered drug, with excellent results in the early stages of 
tonsillitis. The applications should be made every six hours. 

This preparation is now made in America and there is no need of 
prescribing it except under the official British name. 

ATOPHAN. 

Acidum Phenylcinchonictjm, U. S. (See Novatophan.) 

ATOXYL. 

Atoxyl, or the sodium salt of para-amido-phenyl-arsenic acid (Ehr- 
lich), has the chemical formula C 6 H 5 NH As0 2 , and contains 35.6 per 
cent, of arsenic. It may be employed as a substitute for the older 
arsenical preparations. Its introduction into medicine depends chiefly 
upon the investigations of Thomas and Breinl, who, in endeavoring to 
discover a remedy for trypanosomiasis, sought an arsenical compound 
which would prove toxic to trypanosomes and yet have a minimum 
toxicity for human beings. It is usually considered that atoxyl is 
about one-fortieth as toxic as Fowler's solution. Up to the present 
it is one of the best remedies that we have for combating infection 
in human beings by the trypanosome, but arsphenamine is far more 
safe and powerful for good. (See Arsphenamine.) 

The drug has also proved itself of value in relapsing fever, in 
which disease it attacks the Sjiirillum Obermeieri, in African tick fever, 
and in syphilis in all its stages. A very large number of investiga- 
tions have proved that it occupies the position of being "the third 
specific" in the latter disease, salvarsan and mercury coming first. 
Atoxyl has also proved of value in leukcemia. It has also been used in 
malarial infection, but it is less curative and more toxic by far than 
quinine. The proper dose in all these diseases is 7 grains (0.5) given 
hypodermically or intramuscularly. This dose should be given on 
two successive days, with an interval of ten days before the next dose. 
The drug should be dissolved in water in from 5 to 15 per cent, strength, 
and sterilized by boiling for two minutes. As aqueous solutions of 
atoxyl keep badly, they should be freshly prepared. It causes little 
local irritation, and in this dose, when given to adults, rarely, if ever, 
produces poisonous symptoms. Larger doses than this, or this dose, 
if too frequently repeated, may develop permanent blindness through 
atrophy of the optic nerve, and stopping the drug may not arrest 
this change. The visual field is concentrically diminished, but more 



136 DRUGS. 

on the nasal than on the temporal side. Occasionally susceptible 
persons suffer from abdominal cramps and gastro-intestinal disturb- 
ance, or from dysuria, anuria, headache, vertigo, tinnitus, and deaf- 
ness if the drug is freely given. In all of the diseases in which atoxyl 
has been given successfully for the purpose of combating infection by 
micro-organisms, it has been found essential to continue its adminis- 
tration over a long period of time, and in the case of trypanosomiasis 
it has been found that if the drug is given in small quantity the trypan- 
osomes develop an immunity to it, with the result that the use of larger 
doses is futile, the parasites being able to withstand larger amounts than 
the patient can bear. The drug must be used freely and constantly ; 
enough to kill the parasite, but not freely enough to blind the patient. 
It has been largely displaced by salvarsan. 

AZEDARACH. 

Azedarach is the bark of Melia Azedarach, or Pride of China, as 
it is sometimes called. It is found in Syria, Persia, the north of 
India, and in the Southern United States. 

The berries have but little toxic power, and children may eat of 
them largely without ill effect, but the bark is poisonous when taken 
in overdose, and produces symptoms resembling those of poisoning 
by spigelia or belladonna. It is employed as a remedy for the round- 
worm, and should be given in decoction made by boiling 2 ounces 
(60.0) of the bark in 1J pints (720 mils) of water until only a pint 
(480 mils.) of liquid remains. Of this, from 1 to 2 tablespoonfuls 
(16.0-30.0) are to be given a child, and repeated every two hours 
until the bowels are opened. It has also been used as a fluidextract 
prepared by the ordinary means with alcohol, to which some white 
sugar should be added. The dose of this fluidextract is a teaspoon- 
ful (4.0), and it is not to be repeated. The decoction is the best form 
in which to use the drug. 

BALSAM OF PERU. 

(Balsamum Perumanum, U. S. and B. P.). A balsamic exudate 
from Toluifera Pereirce, is a viscid liquid of a dark brown color, agree- 
able odor, bitter acrid taste, producing a burning sensation in the 
throat, soluble in absolute alcohol, chloroform, and glacial acetic acid, 
and only partially soluble in' ether and alcohol. Internally it has 
been employed as a stimulating expectorant. Externally it is com- 
monly used in healing salves. One drachm (4.0) of balsam to 7 (28.0) 
of simple cerate is useful in the healing of cracked nipples and indo- 
lent ulcers. Mixed with vaseline and rubbed over the hands it 
prevents disagreeable odors remaining on the skin after treating 
ulcerative surfaces or making postmortem examinations. Applied 
over a large area of the body as a remedy for scabies it may cause 
acute nephritis. 



BELLADONNA. 137 

BARBITAL AND BARBITAL SODIUM. 1 

Barbital, German name Veronal (Barhitonum, B. P.), is a compound 
of urea, its chemical name being diethylamalonylurea. It occurs in 
fine white, crystalline powder, which is odorless and has a faintly 
bitter taste. Barbital is soluble in 145 parts of water and for this 
reason is always given in capsule or cachet. -Its action is allied to 
that of trional and it is said to have no effect upon the blood or 
respiration. 

It is used to produce sleep, to a limited extent as a pain reliever, and 
is commonly given in capsule in the dose of from 5 to 10 grains (0.3- 
0.6) taken half an hour before retiring for the night. The drug is 
prone to lose its effect if given continuously for more than two weeks. 
When given for a long period the bowels must be kept freely open and 
alkalies administered. It is a most satisfactory hypnotic in nervous 
insomnia and is singularly free from after-effects. When taken in 
full dose it will often cause ataxia, hallucinations, and tremor. 

Very large doses of barbital are necessary to produce death, prob- 
ably more than 150 grains. When a poisonous dose is taken sleep 
lasts about two or three days, and rarely sleep lasts for ten days. 
The heart and respiration act normally in the mild cases, and pupil- 
lary reactions are maintained. When a lethal dose is injected the 
action of the heart and respiration become irregular, Cheyne-Stokes 
breathing develops and cyanosis ensues, followed by death, usually 
not for at least twenty-four hours. 

Under the name of Barbital Sodivm, German name Medinal, 
a soluble salt (1 to 5 of water) of barbital has been introduced, 
which can be given in solution by the mouth or rectum. When 
used hypodermically 7 grains (0.5) are dissolved in 75 minims (5.0) 
of distilled water. The dose is the same as that of barbital. Barbital 
Sodium also acts more rapidly when given by the mouth than does 
barbital because.it is soluble. It is best administered in tablet form 
or in hot sweetened water. 

BELLADONNA. 

Belladonna is botanically known as Atropa Belladonna, and is 
official in the form of the root (Belladonna Radix, U. S. and B. P.) and 
leaves (Belladonna? Folia, U. S. and B. P.). The root should yield 
not less than 0.45 per cent, of the total alkaloids and the leaves not 
less than 0.3 per cent. Its popular name is "deadly night-shade." 
The drug belongs to a very large class of plants, namely, the Solanaceoe, 
all of which have a similar physiological action. Belladonna contains 
an active principle in the form of an alkaloid known as atropine 

1 As veronal and medinal are familiar terms, reference is made to them at first impulse, 
but physicians should use the American terms Barbital and Barbital Sodium, as by 
so doing they use American-made drugs and the holders of German patent rights do 
not profit. 



138 



DRUGS. 



Fig. 16. 



(Atropina, U. S. and B. P.), which is insoluble in water. It should 
be kept in well-closed containers, protected from light. Atropine pos- 
sesses a bitter, acrid taste (it should be tasted with the utmost caution 
and only in dilute solution). The sulphate of atropine (Atropines Sul- 
phas, U. S. and B. P.) is very soluble, and is the salt commonly used. 

Physiological Effects. — In man, full medicinal doses produce flush- 
ing of the face, redness and dryness of the fauces, dilated pupils, 
sometimes an erythematous rash over the skin, rarely diplopia and 
delirium. If the dose be still larger, the delirium becomes marked, 
and is wild and talkative. The pulse is rapid and wiry. The rash 
which appears resembles that of scarlet fever, but lacks the punctua- 
tions. The skin may desquamate after the lapse of several days if 
the rash is severe. 

In children belladonna is usually borne very well. When the 
action of belladonna asserts itself in children and in susceptible adults 
the respiration is quickened, the eyes become bright and the cheeks 
red, but lines of pallor reach from the malar bones to the angles of 
the mouth, giving to the face a curious expression. 
Absorption. — This drug is very rapidly absorbed. 
Nervous System. — Belladonna when given in medicinal amount 
approaching the toxic dose acts as a powerful excitant of the brain, 

producing talkative delirium. Lo- 
cally applied, it depresses the per- 
ipheral sensory nerves. 

When very large doses are given 
to animals, paralysis of the spinal 
cord comes on, followed by tetanic 
spasms, and finally by recovery. 
The primary loss of power is due 
to paralysis of the entire cord, and 
the second state, of convulsions, to 
the escape of the motor and sensory 
pathways from the paralysis before 
the inhibitory centres recover. As a 
result, any peripheral irritation causes 
violent explosions of motor power. 1 
Even in large medicinal dose bella- 
donna may be considered as a de- 
pressant to the motor nerves and as 
a quieter to sensory nerve filaments. 
On voluntary muscles the drug has no 
effect, but upon unstriped muscles it acts as a sedative and anti- 
spasmodic. It distinctly lessens reflex action. 

1 If a homely simile, found useful by the writer in teaching, may be used, the inhibi- 
tory centres may be represented by a schoolmaster and the motor and sensory centres 
by two boys. The escape of chloroform in the room paralyzes them all, but, finally, 
the boys recover before their master and go off as truants (convulsions) ; at last the 
master (inhibitory centres) recovers, and order, or health, is restored. 




A, atropine depresses the peripheral 
vagi and stimulates the accelerator 
nerves (C). 



BELLADONNA. 



139 



Circulation. — Belladonna quickens the pulse by depression of the 
peripheral vagi and by stimulating the cardiac muscle and the accel- 
erator nerves. It has been thought that atropine causes a rise of 
arterial pressure, but recent investigation has thrown doubt upon 
this view. That the drug acts as a powerful agent upon the vascular 
system is certain. It dilates the bloodvessels of the skin, but contracts 
the vessels of the splanchnic area, and this is why it is so valuable in 
collapse and shock, since relaxation of the splanchnic vessels is the 
dominant vascular state in these conditions. The dilatation of the 
capillaries of the skin is in part the cause of scarlet-red skin of 
belladonna-poisoning. 

Fig. 16. 



\i\(WWV^ 



ii 



in 



IV 




Tracing showing the effect of atropine as a vasomotor stimulant (after Schmiedeberg) : I. Normal 
tracing of pressure (126) and pulse 28 in 10 seconds. II. Pressure lowered by pilocarpine to 96, 
pulse 19. III. Tracing continued, pressure 70. IV. Atropine has been given, raising the pressure 
to 145, pulse 30 in 10 seconds. 



In poisonous doses it causes a fall of arterial pressure due to centric 
vasomotor palsy and depression of the muscular coats of the blood- 
vessels, but there is no direct cardiac depression, as has been generally 
taught, for Reichert has proved that the drug is not a heart-depres- 
sant unless the dose is simply overwhelming. Sometimes when bella- 
donna is given the pulse becomes slow, but in these cases the slowing 
is due to temporary stimulation of the peripheral vagi or to momen- 
tary depression of the cardiac motor ganglia. (See Figs. 16 and 17.) 



140 DRUGS. 

Respiration. — Atropine is a stimulant to the respiratory centre 
in ordinary amounts, but recent careful studies show that its high 
reputation as a respiratory stimulant is not based either on clinical 
or experimental evidence. In many cases it fails to increase the 
respirations at all, and it is certainly inferior to caffeine and strych- 
nine in the treatment of opium-poisoning. In large doses it is a 
depressant and paralyzant to respiration, and produces death from 
respiratory failure due to paralysis of the motor nerves supplying 
the respiratory muscles, and probably by depressing the respiratory 
centres. 

Abdominal Viscera. — Belladonna increases peristalsis by depress- 
ing the peripheral ends of the inhibitory fibres of the splanchnic 
nerves, and by diminishing any tendency to spasm on the part of the 
muscular coats of the intestine. The splanchnic effect has been 
denied. 

Action on Secretion. — The drug decreases all the secretions of 
the body except the urine, which is sometimes increased in amount 
under its use. The decrease of secretion is due to paralysis of the 
peripheral nerve-filaments supplying the secretory cells of the glands. 

Bodily Heat. — When belladonna is used in large amounts there 
is nearly always a rise of temperature, which in children may amount 
to one or two degrees. This is probably due to stimulation of the ther- 
mogenic centre in the corpus striatum. In advanced poisoning the 
temperature rapidly falls. 

Elimination. — Atropine is eliminated by the kidneys and bowels 
with extraordinary rapidity, and this is one of the reasons why death 
from poisonous doses of the drug is so rare. J. Harley asserts that 
it is entirely eliminated in two hours, and Meuriot states that not a 
trace of it can be found after twenty-four hours, and that it is partly 
destroyed in the liver. In a case of suspected poisoning the urine of 
the patient may be dropped into the eye of an animal, when, if atro- 
pine or belladonna has been taken, mydriasis will result. 

Eye. — On the eye belladonna produces dilatation of the pupil in 
part by a depressant action on the endings of the oculomotor nerve 
in the iris, by causing a paralysis of the circular muscle-fibres in the 
iris and perhaps by a stimulant effect on the peripheral sympathetic 
nerve-fibres. The dominant action of the drug is undoubtedly the 
depression of the circular muscular fibres of the iris. Associated with 
mydriasis there is also paralysis of accommodation due to the paraly- 
sis of the ciliary muscles by the effect of the drug on the oculomotor 
nerve. Belladonna generally increases intraocular tension. 

Poisoning. — Poisoning by atropine is an exceedingly common occur- 
rence, but death is rarely produced by it, partly because its influence 
is not very actively exercised on vital parts, and partly because it is 
eliminated by the kidneys almost as rapidly as it is absorbed from 
the stomach. Recovery has occurred after as much as one grain of 
atropine has been taken by a child of three years. Aside from the 



BELLADONNA. 141 

symptoms of mild poisoning detailed under the heading of physio- 
logical action, severe poisoning is characterized by deep sleep, pre- 
ceded, it mav be, by convulsions, violent delirium, blindness, and 
sometimes loss of speech. 

Treatment of Poisoning. — Poisoning by belladonna is to be 
treated by emetics, the application of external heat if the patient 
passes into collapse, and the use of strychnine if respiration fails. 
Opium may be employed in carefully graded doses as the physiologi- 
cal antagonist ; but large doses are of doubtful service, particularly 
if the respirations are not in a satisfactory state. 

Therapeutics. — Belladonna is used to allay excessive secretion, to act 
as an antispasmodic, and to influence the circulatory apparatus when 
local inflammations are beginning, particularly in secretory glands, 
and to act as a vasomotor stimulant (Fig. 17). In cardiac palpita- 
tion small doses of belladonna internally, or its external use over the 
praecordium in the form of the plaster or ointment, is very valuable. 

For the relief of local nerve-pains it is of value, and probably acts 
by quieting the irritated nerve. It should be applied in these cases 
in the form of an ointment or plaster, and if the ointment is used it 
should be well rubbed into the part affected. 

To check secretion in night-sweats it is one of the most powerful 
remedies we have, and it is useful in excessive idiopathic pti/alism, as 
seen in children, or in that due to mercurialization. In broniidrosis 
of the feet and other localized sweatings it is useful, and may be em- 
ployed locally or taken internally for their cure. It is the most effi- 
cacious drug we have for checking the secretion of milk in an inflamed 
breast, and under these circumstances it is to be smeared over the 
gland in an ointment. Belladonna mav be used in serous diarrhoea, 
as it checks the disorder by stimulation of the splanchnic vasomotor 
filaments of the intestinal bloodvessels, which being inactive permit 
a transudation of liquid into the bowel. 

Trousseau recommended as a local remedy 1 to 2 grains (0.06- 
0.12) of the extract of belladonna with 6 to 8 grains (0.40-0.50) of 
tannic acid in leucorrhoea dependent upon disease of the uterine cer- 
vix. This should be placed on a pledget of cotton and applied to the 
affected part daily, being allowed to remain all day. Ringer states that 
if pain is also present in these cases the following injection is of value : 

R— Sodii bicarbonatis . . *j (4.0). 

Tincturse belladonna? foliorum . . . . : . . . f3iij (12.0). 
Aqua? destillatae q. s. ad Oj (480 mils.). — M. 

This is to be injected into the vagina, the woman first being placed 
on the back with the buttocks raised, so that the drug may bathe the 
uterine cervix for some minutes. 

As an antispasmodic, atropine is to be used in acute torticollis, in- 
jected directly into the muscle itself so as to act on its motor nerve- 
fibres; it may be given in spasm of the intestines with cramps and 
griping. In cramps in the legs and body, either as a local application 



142 DRUGS. 

by means of liniments or when employed internally, it is of service. 
In asthma of the spasmodic type belladonna is a sovereign remedy, 
particularly if it be combined with morphine. It may be used both 
as a prophylactic and as a cure during the attack. Belladonna-leaves 
may be smoked by asthmatics by rolling them into a cigarette or 
putting them into a pipe. 

This drug is used in whooping-cough at all ages and in all stages, 
but it must be given in large amounts and is only a palliative. 

In spasm of the sphincter ani, whether it be due to fissure or other 
cause, belladonna in the form of an ointment or suppository is of 
value. In spasm of the urethra and bladder the drug may be used 
internally and externally, and in the former state the ointment should 
be smeared along the under surface of the penis every night. This 
treatment is also useful in chordee. In the colic resulting from the 
passage of hepatic and renal calculi atropine in full dose by the hypo- 
dermic needle combined with morphine will very often give relief. 
Where urinary incontinence depends upon spasm of the bladder bella- 
donna should be used. (See Incontinence of Urine.) In dysmenor- 
rhea in nervous women, with spasm of the cervix uteri, it is of value 
applied as an ointment or in a vaginal suppository, or when given 
by the mouth. For the nervous cough of children and adults bella- 
donna is one of the best remedies we have. In constipation it does 
good by depressing the inhibitory nerves of the intestine. It is 
also of value in laryngismus stridulus and in hiccough. In spasm 
from peripheral irritations belladonna is useful. 

In iritis atropine is used to dilate the pupil and prevent adhesions. 
The solution to be dropped into the eye should contain 1 to 4 grains 
(0.06-0.25) of atropine sulphate to the ounce (30.0) of water. (See 
Iritis.) Atropine sulphate is also used for the purpose of producing 
mydriasis before ophthalmoscopic examination, in solutions of the 
strength just given. It increases intraocular tension and is contra- 
indicated in glaucoma. 

When employed to act on the circulation, it is to be used in shock 
and collapse from injury or in the course of severe disease. (See 
Shock.) During the progress of a case of pneumonia, typhoid fever, 
or other severe disease belladonna should be kept in the house, and 
administered freely if collapse or relaxation of the splanchnic vessels 
suddenly asserts itself. Particularly is this true in the case of pneu- 
monia. The vascular system during the crisis of this disease will 
often be found much relaxed, and heart stimulants do not seem to do 
much good. The administration of atropine or belladonna will dry 
the leaking skin, and by increasing the vascular tone produce great 
improvement. A large dose of atropine, given hypodermically, is the 
best remedy we have in pulmonary oedema, and for the relief of the 
symptoms of anaphylaxis after the use of antitoxin. The hypodermic 
use of atropine before administering chloroform greatly increases the 
safety of this anaesthetic. (See also Scopolamine.) 



BETANAPHTHOL. 143 

In mastitis, or inflammation of the breast, belladonna, if pushed, 
will give surprisingly good results if given internally and applied 
locally. In acute sore throat, when there is a sensation of rawness in 
the pharynx, while the local capillaries appear injected and red, bella- 
donna is often of the greatest service if given in full dose, aborting 
the " cold." 

In exophthalmic goitre belladonna is thought to act by stimulating 
the sympathetic nerves, and certainly gives relief iu some cases, par- 
ticularly if combined with strophanthus or digitalis. 

In headache occurring in young persons, often due to ocular over- 
work, with pain in the eyeballs aud forehead and a sensation as if the 
orbits were too small for the eyeballs, belladonna is of service. In in- 
tercostal neuralgia or pleurodynia belladonna plasters may be applied 
to the spot where the pain is felt, with relief. 

Use of Atropine in Poisoning. — Atropine is a physiological antidote 
to opium, Calabar bean or physostigma, and jaborandi. In opium 
poisoning it acts as an antidote in all parts of the body except the eye, 
and in jaborandi poisoning the same holds true ; but in the former 
condition, although it has been largely used, it is no longer regarded 
as a satisfactory antidote ; caffeine and strychnine are preferable. 
The condition of the pupil is not a guide as to the effect of atropine 
in opium poisoning, because opium acts centrically and atropine acts 
peripherally on the nerves governing the iris. Atropine should be 
used in aconite, antimony, and hydrocyanic acid poisoning for its 
stimulating influence on the vasomotor system, the respiratory centre, 
and the heart, and for the purpose of maintaining the bodily heat, 
the dissipation of which it retards by preventing vasomotor palsy and 
consequent dilatation of the peripheral bloodvessels. 

Atropine is a valuable physiological antidote to poisonous mush- 
rooms, particularly the Amanita, as it is antagonistic to their poison, 
muscarine. The dose given should be large, and, if need be, repeated. 

Administration. — The dose of the sulphate of atropine (Atropinte 
Sulphas, U. S. andB. P.) is - 2 \^ to ¥ V g rain (0.0002-0.0015). 
The alcoholic extract {Extractum Belladonna Foliorum, II. S., Extrac- 
tum Belladonna Siccum, B. P.) is given in J to | grain (0.01-0.015) 
doses, and the tincture (Tinctura Belladonna? Foliorum, U. S.; 
Tinctura Belladonna?, B. P.) in the dose of 5 to 40 minims (0.3-2.6), 
5-15 minims (0.3-1.0) B. P. Both these preparations are derived 
from the leaves. The extract of belladonna leaves should contain 
1.18 per cent, to 1.32 per cent. (B. P. 1 per cent.) of alkaloids. The 
tincture of belladonna leaves should contain 0.027 Gm. to 0.033 Gm. 
of total alkaloids in each 100 mils. The fluidextract (Fluidextractum 
Belladonna Radicis, U. S.) is given in 1- to 2-minim (0.06-0.12) 
doses, but Extractum Belladonna? Liquidum is given in J- to 1-minim 
(0.015-006) doses. These preparations are derived from the root. 
The fluidextract of belladonna root contains 0.405 to 0.495 Gm. of 
alkaloids in each 100 mils. Belladonna liniment {Linimentum 



144 DRUGS. 

Belladonna;, U. S. and B. P.), belladonna plaster (Emplastrum Bella- 
donna, U. S. and B. P.), the ointment ( Unguentum Belladonna, 
U. S. and B. P.) are for external application. The preparations of 
the B. P. not official in the U. S. P. are Liquor Atropine Sulphatis, 
dropped in the eyes in the dose of J to 1 minim (0.03-0.06) ; Lamella 
Atropine, each of which contains, 5~<ro~o grain of atropine; and Unguen- 
tum Atropina and Extractum Belladonna Alcoholicum, derived from 
the root. Succus Belladonna, B. P., is given in 5- to 15-minim 
(0.3-1.0) doses. There is also official in the B. P. a suppository 
(Suppositoria Belladonna) which contains 1| grains of the extract. 
Contraindications. — Belladonna decreases salivary and gastric secre- 
tion very considerably in some persons. It is better, therefore, not 
to administer it just before or immediately after a meal, unless it 
is desired to reduce gastric secretion. 

BENZOIN AND BENZOIC ACID. 

Benzoin (Benzoinnm, U. S. and B. P.) is a resinous balsam derived 
from Sty rax Benzoin, which is a native of Sumatra, Borneo, and 
Java, and another unidentified species of Sty rax. It occurs in 
pebble-like bodies or tears, mostly 0.5 to 5 Cm. long and about 
one-fourth as thick, slightly flattened, straight or curved, yellow- 
ish- to rusty-brown externally, milky-white on fresh fracture, 
separate or very slightly agglutinated (Siam Benzoin), or embedded in 
a dry resinous mass, which varies from reddish-brown to reddish-gray 
or grayish-brown; opaque or slightly translucent and more or less 
lustrous (Sumatra Benzoin) ; brittle, becoming soft on warming, and 
yielding benzoic acid on sublimation ; odor agreeable, balsamic (vanilla- 
like in the Siam variety) ; taste slightly acrid. 

Benzoin is almost wholly soluble in 5 parts of warm alcohol, the 
solution showing an acid reaction to blue litmus paper ; and soluble 
in solutions of sodium or potassium hydroxide. Benzoic acid is ob- 
tained by the sublimation of gum benzoin, or is prepared artificially, 
chiefly from toluol. The last method of preparation is not to be 
recommended, as the acid so made often disorders the stomach and 
leaves a disagreeable taste in the mouth. It is benzoic acid which is 
generally used in medicine. 

Physiological Action. — Locally applied in concentrated form, ben- 
zoic acid is an irritant, and taken internally in excessive amount it 
causes a sensation of warmth and burning. It is eliminated as hip- 
puric acid and increases the acidity of the urine. It is an antiseptic 
and germicide. In persons having an idiosyncrasy to benzoic acid it 
is not uncommon for urticaria to follow the use of the drug. Some- 
times a papular or erythematous eruption appears after its use. The 
action of this drug in the system is closely allied to that of salicylic 
acid, in that it increases metabolic chauges in the tissues. It also 
decreases putrefactive changes in the intestine. 



BETAXAPHTHOL. 145 

Therapeutics. — Benzoic acid is useful in the treatment of chronic 
cystitis with alkaline urine which is loaded with phosphates, and com- 
bined with cannabis indica, acts well in the later stages of gonorrhoea. 
Senator states that in the dose of 2 or 3 drachms (8.0-12.0) a day it 
is a specific in acute rheumatism, and thinks it equal to salicylic acid. 
When these doses are to be used, the benzoate of sodium should be 
employed, owing to its solubility. In acute laryngitis accompanied 
by great hoarseness the inhalation of steam laden with compound 
tincture of benzoin is of the greatest service. A tablespoonful (15.0) 
of this tincture should be placed in a pitcher of boiling water, the 
face held over the liquid, and a towel thrown over the head of the 
patient to retain the steam. The drug cannot be used in an atomizer, 
as it clogs the " tips." Taken internally, benzoic acid is useful as an 
expectorant in chronic bronchitis in the dose of 10 grains (0.60) three 
times a day. 

Administration. — The dose of benzoic acid (Acidum Benzoicum, 
IT. S. and B. P.) is usually 10 to 40 grains (0.6-2.6), 5-15 grains 
(0.3—1.0), B. P., but a drachm may be given in capsule. The balsam 
itself is never used as such. The tincture (Tinctura Benzoini, U. S.) 
is given in 30-minim to 1-drachm (2.0-4.0) doses, and the compound 
tincture (Tinctura Benzoini Composita, U. S. and B. P.), composed of 
benzoin, purified aloes, storax, balsam of Tolu, and alcohol, the 
dose of it being 1 to 2 fluidrachms (4.0-8.0). The preparations, 
official in the B. P., but not in the U. S. P., are the troche (Trochiscus 
Acidi Benzoici) and Unguentum Cetacei. 

Adeps Benzoinatus (U. S.) and Adeps Benzoatus (B. P.), or ben- 
zoated lard, is a non-rancid basis for many ointments, notably that 
of zinc. 

BETANAPHTHOL. 

Betanaphthol, U. S., or Xaphthol, B. P. A monhydric phenol 
occurring in coal-tar, but usually prepared from naphthalene. It 
should be kept in dark amber-colored, well-stoppered bottles. It 
occurs as a colorless or pale buff-colored, shining crystalline laminae 
or as a white or yellowish-white crystalline powder, having a faint 
phenol-like odor and a sharp and pungent but not persistent taste. 
It is permanent in the air. It is soluble in about 1000 parts of water, 
0.8 part of alcohol, 17 parts of chloroform, and 1 .3 parts of ether at 
25° C. (77° F.) ; in about 80 parts of boiling water; soluble in glycerin 
and olive oil and easily dissolved by alkali hydroxide solutions. 

It is used externally in antiseptic dressings. Internally it is an 
excellent remedy for gastric fermentation and flatulence, as it acts as 
an active antiseptic. It is also useful in fetid diarrhea of the serous 
type, and is valuable in uncinariasis. The dose is 2 to 5 grains (0.12- 
0.3) in capsule or cachet. The drug is useful as a local parasiticide. 

Betanaplithol-bismuth (Bismuthi Betanaphtholas, Y. S.), or Orphol, 
is a neutral, odorless, and tasteless powder designed to combine the 
10 



146 DRUGS. 

sedative effects of bismuth with the antiseptic properties of beta- 
naphthol. It is used in cases of serous and fermentative diarrhoea 
in adults in the dose of 5 to 15 grains (0.3-1.0) and in children in 
the dose of 2 to 5 grains (0.12-0.3) given every few hours in capsule. 

Benzonaphthol is used as a substitute for betanaphthol in fermenta- 
tive dyspepsia. The dose is about 10 grains (0.6) three times a day, 
and it is best given in cachet. 

BISMUTH. 

Bismuth is employed in several forms or salts as follows, and is a 
valuable remedy. 

Bismuth Subgallate. 

Dermatol, or the subgallate of bismuth (Bismuthi Subgallas, U. S.), 
is a fine bright yellow powder which is unaffected by prolonged 
exposure to light and air, is odorless, and is supposed to contain from 
52 to 57 per cent, of oxide of bismuth. Its external uses are identi- 
cal with those of iodoform, and it probably acts in much the same 
manner as does the latter drug — namely, by so drying the wound 
that it becomes an unfavorable site for the growth of germs. As 
dermatol is an astringent, it cannot be employed in the treatment of 
indolent ulcers which need stimulation rather than an astringent in- 
fluence, and it would seem probable on theoretical grounds that it is 
not to be compared to iodoform in the treatment of cases in which 
tubercular processes are active. 

There is no doubt that dermatol is less poisonous than iodoform, 
but it must be capable of producing some untoward effects if used 
freely for any length of time, since poisoning follows the prolonged 
employment of other bismuth preparations, as has been determined by 
Balzer, Dalch6, and Villejean, for the symptoms of which see the 
article on Bismuth Subnitrate. 

Dermatol may be tried in cases of skin disease in which there is 
much secretion, as in weeping eczemas and similiar states, either in the 
form of a dusting-powder or in an ointment with vaseline or lanolin 
in the proportion of \ to 1 drachm to the ounce (2.0-4.0 : 30.0). 
Sometimes its efficiency can be much increased by the addition of a 
drachm (4.0) of oxide of zinc to the prescription just given. 

Dermatol has been used with marked success in case of purulent 
otitis media as a dusting-powder, and in other states requiring similar 
drying and astringent effects. 

Internally, it has been highly recommended in cases of fermenta- 
tive dypepsia in the dose of 5 to 10 grains (0.3-0.60), but its real 
value in this condition is as yet undetermined. 

Bismuth Subnitrate and Bismuth Subcarbonate. 

Bismuthi Subnitras (U. S. and B. P.), and Bismuthi Subcarbonas 
(U. S.), or Bismuthi Carbonas (B. P.), occur as white amorphous 



BISMUTH. 147 

powders. Occasionally the subcarbonate may be a pale yellowish 
white. They may be used interchangeably, as they possess the same 
properties. The subnitrate should contain not less than 79 per cent, 
of bismuth oxide and the subcarbonate not less than 90 per cent. 
They are both insoluble in water except to a very slight degree. 

Physiological Action. — Bismuth in the form of subnitrate and 
subcarbonate is ordinarily devoid of effect upon the general sys- 
tem, and locally applied externally, or when given internally, exer- 
cises a mild astringent and protective influence upon mucous mem- 
branes. 

It may produce chronic poisoning after prolonged use on wounds 
or when internally administered in excessive doses for some time. 
Ordinary doses are innocuous. As much as 4 to 5 drachms a day 
may be given for a short time without harm. The changes which 
ensue when the drug is abused are pallor of the face, the formation 
of a black line on the gums, black sloughs in the mouth and gastro- 
intestinal tract, swelling of the tongue, salivation, desquamative 
nephritis, and albuminuria. Oliver states that a blue line on the 
gums resembling that seen in lead poisoning may develop. 

Two deaths in children have been reported under these conditions. 
One by Benecke and Hoffmann and one by Bonnie. The latter has 
shown that the subnitrate is capable, under the influence of certain 
bacteria in the intestine, of giving off nitric acid and nitrites, and the 
symptoms of poisoning have been shown by Bohme to be due to the 
latter. The haemoglobin is changed into methsemoglobin, as it is when 
the nitrites are used medicinally in large amounts. For this reason 
the subcarbonate is to be used in preference to the subnitrate for 
X-ray examinations. 

The use of bismuth in single massive doses of as much as 2 to 4 
ounces (60.0-120.0) for the purpose of rendering the walls of the 
stomach opaque to the X-rays in cases of suspected gastroptosis or 
dilatation has produced in some cases nausea, vomiting, prostration, 
cyanosis, and rapid pulse and quickened respiration. Formerly this 
drug was supposed to be capable of producing acute gastro-enteritis, 
when given in large doses, but this was due to contamination by arsenic. 

Therapeutics. — Bismuth subnitrate and subcarbonate are used as 
mild astringents in large doses to cover the surface of inflamed mu- 
cous membranes and so to allay irritation. It is useful in irritative 
vomiting for this reason, and in diarrhoea of a similar type in which 
the stools are serous. If the passages are mucous, castor oil should 
precede bismuth in order to rid the alimentary canal of the mucous 
secretion already poured out. It is very useful when combined with 
phenol in serous diarrhoea, given in capsules containing 10 grains 
(0.60) of bismuth subnitrate and 1 minim (0.05) of phenol. It may 
also be used as a slowlv acting and feeble antacid. Bismuth is of 
service in dyspepsia when lactic- and butyric-acid fermentation is 
present with excessive belching, and may be employed in gastralgia 
and gastric ulcer and gastritis as a sedative and astringent. 



148 DRUGS. 

Milk of Bismuth (Magma Bismuthi, U. S.) is a suspension of hydrox- 
ide of bismuth now placed upon the market, the bismuth being 
minutely subdivided so that the tiny particles float in distilled water. 
It contains no glycerine, mucilage, sugar, or other substance, and 
each teaspoonful represents 5 grains of bismuth subnitrate. The 
dose varies from \ drachm to \ ounce, the latter dose being given to 
adults with gastric ulcer and the smaller dose to children with gastric 
irritation or acute gastric catarrh. It may also be employed as a lotion 
to superficial burns and in intertrigo. 

Bismuth subcarbonate mixed with petrolatum in the proportion of 
33 per cent, has produced excellent results when injected into tuber- 
cular and other sinuses, and in all forms of chronic empyema. Not 
more than 1 ounce is usually necessary, and larger amounts may 
cause poisoning. If symptoms of poisoning arise, the bismuth paste 
must be washed out with warm olive oil; if not it may be allowed to 
remain in the cavity indefinitely. The opening should not be closed, 
but dressed with gauze. After the discharge becomes sterile the 
paste may be replaced by sterile vaseline. 

When the salts of bismuth are used for any length of time they 
cause the odor of garlic in the breath, which is due to the presence 
of an exceedingly slight trace of tellurium in the bismuth. The stools 
are apt to become black under the influence of bismuth, and the tongue, 
if furred, may also be black about the centre when bismuth is used. 

Where there is chapping of the hands or cheeks from exposure to 
cold or wet the following prescription is useful : 

1^— Bismuthi subnitratis Siij (12.0). 

Zinci oleatis 3iij (12.0). 

Lycopodii , . by (8.0);.— M. 

S. — Apply to the parts t. i. d. 

Bismuth Subsalicylate. 

Subsalicylate of Bismuth (Bismuthi Subsalicylas, U. S., and Bis- 
muthi Salicylas, B. P.) is a white, soft powder, insoluble in water, 
alcohol, ether, and chloroform, but soluble in acids. It should con- 
tain not less than 62 per cent, nor more than 66 per cent, of bismuth 
oxide. It is largely used by some practitioners as an intestinal anti- 
septic in cases in which there is diarrhwa due to fermentation or putre- 
faction. It may be given in powder, or, better still, in capsule, in the 
dose of 3 to 15 grains (0.2-1.0) several times a day. 

Bismuth Citrate and Ammonium Citrate. 

Bismuthi et Ammonii Citras (U. S.) is employed as a remedy for 
serous diarrhea. They are more irritating and astringent than the 
other salts of bismuth. The ammonium citrate contains not less than 



BORAX AND BORIC ACID. 149 

46 per cent, of the oxide of bismuth. The dose of these salts is 
2 to 4 grains (0.12-0.25). In the B. P. the following preparation is 
official: Liquor Bismuthi et Ammonii Citratis, dose J to 1 fluidrachm 
(2.0-4.0). 

BORAX AND BORIC ACID. 

Borax Purificatum, B. P., or Sodii Boras, IT. S., may be made by 
the action of boracic or boric acid upon soda, but the drug as it 
appears in commerce of America is derived entirely from natural 
deposits found on the shores of lakes in California and Nevada. 
The natural product has to be purified before it is marketable. 
Borax is soluble in 15 parts its weight of water at 77° F., and 0.6 
part in boiling water. Both borax and boric acid have been supposed 
to act as efficient germicides in strong solutions, but this has been 
proved incorrect. They are antiseptics, however, even in weak 
solutions. 

Upon the body borax has little effect in any dose which is given for 
medicinal effect. It is rapidly eliminated and renders the urine 
alkaline. It is too rapidly absorbed from the alimentary canal to 
permit it to act as an intestinal antiseptic. Boric acid exercises even 
less effect upon the system than borax. Borax may also be used as 
a gargle in diphtheria, in aphthous stomatitis, cancrum oris, and gan- 
grenous stomatitis. In the treatment of pruritis ani and vulvce and 
in bromidrosis and fetid sweating it is of great value when used in 
solution as a wash. Strong solutions, locally applied, are useful in 
tinea tonsurans and tinea circinata. 

Borax has been used very largely in the treatment of epilepsy, with 
asserted success in some cases. Its employment is purely empirical. 
The dose used is from 8 to 15 grains (0.5-1.0), gradually increased 
until it produces disturbance in the alimentary canal. As the taste 
is very disagreeable to most persons, the drug should be used with 
liquorice, strong coffee, or syrup of bitter orange : 

I^-Sodii boratis . . . gss (16.0). 

Glycerini f§j (30.0). 

Fluidextracti glycyrrhizse fgij (60.0). 

Aquae destillatae q. s. ad. f §vj (180.0).— M. 

S. — Dessertspoonful (8.0) in water after each meal. 

If larger doses than 15 to 30 grains (1.0-2.0) a day are continued 
after the convulsions are decreased in number, there are two difficul- 
ties : first, the good effect is rapidly lost ; and, second, untoward 
symptoms, such as nausea and diarrhosa, with emaciation and the 
formation of a scarlatinal, eczematous, or papular eruption, appear. 
A peculiarity of the last two eruptions is that they are distributed 
around the joints. 

A very useful wash for oral and nasal mucous membranes is " Dobell's 
solution/' which is composed of — 



150 DRUGS. 

R— Sodii boratis, 

Sodii bicarbonatis . . . aa 5"i (4.0). 

Phenolis gr. xxx (2.0) 

Glycerini f ^j (30 .o). 

Aquae purae Qi'j (960 mils.).— M. 

Boric acid (Acidum Boricum, U. S. and B. P.) is one of the most 
commonly used substances in eye-washes, either alone or with cocaine. 
When used with cocaine or other drugs it is employed to prevent the 
destruction of the alkaloid or glucoside, as the case may be, by the 
growth of mould. The following formula may be employed : 

R— Cocainae hydrochloridi gr. iv vel viij (0.25-0.5). 

Acidi borici gr. x vel xx (0.65-1.3). 

Aquse destillatae fgij (60.0).— M. 

S. — To be used by dropping into the eye. 

The official ointment ( Unguentum Acidi Borici, U. S.) or the follow- 
ing makes a very useful application for the skin of the face and hands, 
to prevent chapping : 

R— Acidi borici gj (4.0). 

Cera? albas 5j (1.0). 

Paraffini 3ij (8.0). 

Olei amygdalae expressi fjij (8.0).— M. 

S. — To be thoroughly mixed and applied night and morning. 

In the form of a lotion boric acid has been used with some success 
as a remedy for erysipelas, and it may be similarly employed in burns 
and scalds. 

Boric acid may be given internally in cystitis to render the urine 
acid, and is useful in the removal of freckles when applied as a wash 
to the skin. In persons having an idiosyncrasy to boric acid a bul- 
lous eruption of the skin may follow its use. 

Borated lint is made by dipping lint into a boiling saturated solu- 
tion of boric acid or borax. It is a simple, inexpensive antiseptic 
surgical dressing, and contains nearly one-half its weight of the drug. 
Mel Boracis, B. P., is not official in the U. S. P. It is used as a local 
application for sore mouth. 

BROMETONE. 

Brometone is produced by the action of caustic alkalies upon 
bromoform and acetone; it occurs in fine white prismatic crystals 
which possess a camphoraceous odor and taste. Its melting point is 
about 167° C. It is soluble in most of the organic solvents, as alco- 
hol, ether, benzine, etc., slightly soluble in cold and more soluble in 
hot water. Its chemical name is tri-brom-tertiary-butyl-alcohol, and 
it contains 77 per cent, of bromine. 

The physiological action of brometone is nearly identical with that 
of the older bromides. Given in full doses it may, in susceptible 



BROMIDES. 



151 



persons, produce some dizziness, vertigo, loss of appetite, or mental 
heaviness, which are, however, only fleeting in their nature. Brome- 
tone may, therefore, be used as a substitute for the other bromides. 
It possesses the advantage of being powerful and therefore is effica- 
cious in small doses varying from 5 to 10 grains (0.3-0.6) ; best 
given in capsules. 

BROMIDES. 

Bromides of Potassium, Sodium, Lithium, Calcium, Gold, Nickel, 
Ammonium, Strontium, and Hydrobromic Acid. 

Bromide of Potassium. 

Bromide of Potassium (Potassii Bromidum, U. S. and B. P.) is 
the most commonly used and an important member of the group above 
named, and will therefore be spoken of before the others. It is pre- 
pared by precipitating freshly-made bromide of iron with pure car- 
bonate of potassium, or by a process more readily carried out and 

Fig. 18. 




A, the bromides depress the motor areas and B, intellectual areas in the brain ; C, 
they depress the sensory tracts in the spinal cord; D, they depress reflex action by 
depressing the sensory cells in the cord a. 

recommended by the B. P. It occurs in colorless transparent crys- 
tals, which are stable in dry air, but absorb moisture in a damp 
atmosphere. It is very soluble in water, but less so in alcohol. This 
bromide has a salty taste, and is distinctly irritant to mucous mem- 
branes if locally applied in concentrated form. A certain portion of 
its depressant influence, particularly when it is given for long periods 



152 DRUGS. 

of time, depends upon the potassium as much as upon the bromine, 
and for this reason the sodium salt is preferable. 

Physiological Action. — Bromide of potassium has an action upon 
the animal economy, which is clearly defined and closely followed 
by all the other bromide salts, so that what is said in this place 
concerning its effects may be taken as representing the whole claso 
of bromides, except in the instances where slight differences exist, 
which will be pointed out under the various names of the respective 
salts. When taken internally in full doses it produces drowsiness, 
sleep, and a decrease in all the reflexes. (See effects of Prolonged 
Use.) Because of its potash base it is more depressant than the other 
salts, and should be used with care in nephritis. 

Nervous System. — The bromide of potassium acts as a distinct 
depressant to the motor and to the intellectual portions of the cortex 
cerebri. It slows the development of thought and decreases the 
excitability and power of the motor cells of the brain (Albertoni). 
Upon the spinal cord it acts as a marked sedative, affecting chiefly 
the sensory tracts, and causing thereby loss of reflex action and a 
decrease in the ability to recognize pain. It also depresses, but to a 
less extent, the motor pathways in the cord. Motion is maintained 
after sensations to pain and reflexes are lost. The drug depresses the 
peripheral parts of the sensory nerves, and after very large doses the 
motor nerves and muscles are similarly involved. 

Circulation. — If the drug be injected in ordinary dose into the 
jugular vein, it causes at once a fall of arterial pressure and pulse- 
rate. These changes are due to a direct action of the bromine and 
the potassium upon the heart. When given to a man in therapeutic 
doses by the mouth, its circulatory effect is so slight as not to be 
worthy of consideration unless the dose is very large and repeated. 

Respiration. — In toxic dose bromide of potassium is a depres- 
sant to the respiratory centre. In medicinal dose it does not affect 
the breathing, except when the amounts given are large and the drug 
persistently administered, when the breathing becomes slower. 

Digestion. — The bromides may disorder the stomach by irrita- 
ting its mucous membrane or by so decreasing reflex action that the 
proper secretion of gastric juice is retarded, with the result that 
digestion does not take place with sufficient rapidity. For similar 
reasons they may cause constipation. ' 

Temperature. — No effect upon this function is noted unless the 
dose be enormous ; when such a dose is given the bodily heat is pro- 
gressively diminished, the fall of temperature being probably due to 
the circulatory and nervous depression produced, associated with the 
general failure in vital power. 

Elimination. — The drug escapes unchanged very slowly with all 
the secretions, and is found in the sweat, urine, tears, semen, milk, 
and faeces. 

Tissue-waste is decreased when the animal economy is under the 
influence of one of the bromides. 



BROMIDES. 153 

Therapeutics. — From what has been said, it is evident that bro- 
mide of potassium is a remedy to be devoted almost entirely to the 
treatment of disorders of the nervous system, and its uses are, 
therefore, as various as the manifestations of perversion of nervous 
action can be various. In a word, it may be said that bromide of 
potassium is to be used wherever over-excitement of nervous proto- 
plasm is present, but never where nervous symptoms are due to 
depression. 

In epilepsy, which, to the best of our knowledge, is due to explo- 
sive impulses arising in the cerebral cortex, it is one of the best drugs 
we have if given in sufficient dose ; and in all forms of minor spasm, 
due to heightened reflex activity, it is of service. Care should be 
used in giving this drug in epilepsy that it is not used so long as 
to impair the mental state and that maniacal excitement does not 
supplant the attacks of epilepsy. (See Epilepsy, Part IV.) In 
cases of spasmodic contractions, in the treatment of hysterical females, 
in nervous startings and alarm at sudden noises in adults and children, 
and in the nervous symptoms accompanying pregnancy and the meno- 
pause the bromides will be found of great value. The following 
prescription was recommended very highly by Goodell, and will be 
found of service in the latter states : 

R— Ammonii bromidi . . • 3ij (8.0). 

Potassii bromidi giv (16.0). 

Spiritus ammonii aromatici f 3vj (24.0). 

Aquae camphorae q. s. ad. fgvj (180.0). — M. 

S. — A dessertspoonful (8.0) to a tablespoonful (16.0) every four hours. 

In headaches due to uterine trouble the pain is often felt at the top 
of the skull or at the back of the neck near the occiput. The cause 
of this trouble will sometimes be found to be in the cervix uteri, and 
relief under these circumstances can only be obtained when the uterus 
is treated and the bromides administered. 

In convulsions in children and adults, combined with chloral, bro- 
mides are most efficient, and are sometimes of service in incontinence 
of urine due to vesical spasm. In seminal emissions due to a morbid 
excitability of the centres in the spinal cord, bromide of potassium is 
one of the best remedies we have, and in satyriasis and nymphomania 
it is of great service. 

In cases where undue irritability of the pharynx and larynx prevents 
examination of these parts, one or two full doses will render an ex- 
amination easy of performance by decreasing the local reflex activity. 
This is a useful point to be remembered in relation to the treatment 
of pharyngeal and laryngeal disease. 

In cases of acute laryngitis full doses of the bromides (60 to 120 
grains [4.0-8.0] a day) are very useful to allay the pain and hoarseness. 

The bromides are found to be of service in the laryngeal crises of 
locomotor ataxia, the explanation of this fact being as follows : The 



154 DRUGS. 

adductor centre of the larynx is situated in the brain, and the abduc- 
tor centre in the spinal cord. The first closes the layrnx, the second 
opens it, and in health they maintain a patulous tube by their oppo- 
sition. In disease the spinal centre (the abductor or opener) fails, 
and the adductor in the brain, being unopposed, produces closure of 
the tube with disastrous results. The bromide, by quieting reflex 
action, as well as depressing the adductor centre in the cerebral cortex, 
prevents this accident. 

In whooping-cough with much mucous exudation the drug is rarely 
of benefit, and had better not be used. In laryngismus stridulus or 
any form of spasm depeudiiig upon local irritation the local trouble 
must, of course, be removed if possible and the bromides given. In 
teething the drug may be used to decrease reflex irritation and pre- 
vent convulsions, and it will decrease the night-screaming of children 
— which is often due to bad dreams — to a very extraordinary degree, 
even if the dose be quite small. As a soporific for the insane and in 
the insomnia of the overworked and that of nervous women the bro- 
mide of potassium is of great service, but ought to be used as a 
temporary measure ouly. (See Insomnia.) It may also be employed 
with good results in chronic alcoholism and morphiomania, given in 
doses of 40 to 60 grains (2.6-4.0). In migraine and neuralgia due 
to eye-strain or nerve-strain, combined with caffeine, the bromides are 
almost specifics. The caffeine seems to stimulate the depressed nerve 
up to the normal level, and the bromide to deaden the perception of 
the pain. The following is a most valuable remedy in migraine, and 
also in sick headache. It ought not to be used in bilious headache, 
which will often be made worse by it : 

~fy— Antipyrinse gr. xxv (1.6). 

Caffeinae citratae gr. x (0.60). 

Potassii bromidi gr. xxv (1.6).— M. 

Fiant chart ulse, No. v. 

S. — One powder as needed. 

In the treatment of dysmenorrhea and menorrhagia, particularly 
in young subjects, the bromides are also of service. (See GoodelPs 
prescription, page 153.) When the flow is too profuse, the drug 
should be begun a week before the expected epoch, and given in the 
dose of 5 to 10 grains (0.3-0.60) night and morning. In cases 
where the epochs follow oue another too closely the drug should be 
used continuously. After an apparent cure ensues the bromide should 
be continued for a few periods to avoid a relapse For seasickness 
the bromides are the best prophylactics we possess, and should be 
used in the dose of 5 to 10 grains (0.3-0.60) three times a day for 
several days before the patient sails, in order to quiet the vomiting 
centre. After sea-sickness begins they should not be given in ordi- 
nary solution, but in an effervescing draught made as follows : 



. BROMIDES. 155 

R— Acidi citrici 5ij (8.0). 

Aquse destillatae fsjiv (120.0>.— M. 

Fiat solutio. 

R— Potassii bromidi 3j (4.0). 

Potassii bicarbonatis . 3j (4.0). 

Aquae destillatse f 5 iv (120.0).— M. 

Fiat solutio. 
S.— A tablespoonful (16.0) of each of these solutions should be added to one 
another and taken during effervescence. 

This prescription will also be found of value in the persistent vom- 
iting of pregnancy and in that following prolonged etherization or 
other states. If the vomiting is excessive, the dose ought to be 
reduced to 2 teaspoon fuls (8.0) of each solution, and be given every 
half-hour until half of each mixture is taken or the patient is relieved. 
In cases where this cannot be retained, a rectal injection of the fol 
lowing; will be found of value : 

R.— Sodh bromidi gr. xxx vel 3 j (2.0-4.0). 

Tincturae opti deodorati TT\xxx (2.0). 

Mucilaginis amyli fgvj (180. 0).— M. 

S.— To be injected gently into the empty rectum and retained as long as 
possible. 

This method is one of the most reliable plans that can be fol- 
lowed. 

Bromide of potassium may be used to prevent the development of 
symptoms of cinchonism, which often ensue after the use of quinine 
and salicylic acid, and it is said to prevent the nausea and depression 
so apt to follow the use of opium. 

Administration. — The dose of bromide of potassium is from 5 to 
120 grains (0.3-8.0) a day. It should be given at long intervals, as 
it is slowly absorbed and very slowly eliminated. After the patient 
is fully under its influence its effects can be maintained by smaller 
doses. The best way to order it is in a watery solution with a little 
syrup. 

Use of Bromides in Poisoning. — Bromides are useful in nearly all 
convulsive attacks consequent upon the ingestion of poisons, and they 
may be used to allay any nervous symptoms arising from this cause 
which are of an exciting nature. 

Poisoning. — Acute poisoning by the bromides is rare, but if half to 
one ounce is taken they produce a sense of warmth in the epigastrium, 
general feebleness, frontal headache, stupor, aphasia, and amnesia. 
The pulse-rate decreases 15 to 20 beats a minute ; the pulse is irreg- 
ular and compressible. Recovery takes place, as a rule, unless pul- 
monary oedema sets in. Occasionally the patient may become 
maniacal. 

Effects of Prolonged Use, or Bromism. — After the drug has been 
used for some time in large doses acne appears about the face and 
extends over the entire body ; the breath becomes fetid, the patient 
is dull, expressionless, and heavy, and remains buried in sleep during 



156 DRUGS. 

nearly every hour of the day. During this time he can be aroused, 
but at once sinks to sleep again. The gait becomes weak and feeble, 
the movements slow and prolonged. Taste is lost and hearing is 
benumbed, while the intellectual faculties of the brain are almost in 
abeyance. Loss of sexual power is an early symptom. In other 
cases evidences of mental aberration develop, the patient becoming 
irritable, morose, and even homicidal. Sometimes, however, we find 
melancholia and hallucinations, and rarely exalted ideas, 1 with symp- 
toms resembling general paresis. In still others a dangerous suffoca- 
tive bronchitis develops, the patient may become profoundly cachectic, 
or the condition may resemble typhoid fever. The acne may be pre- 
vented to some extent by the use of arsenic, and when the bromides 
are given to women this drug may be given simultaneously to 
prevent the eruption. As Fowler's solution is compatible with 
the bromide in solution, it is the best form of arsenic to employ. 
As the acne is due to a torpid state of the skin-glands, it is also 
well in these cases to order the patient to wash with warm water 
and Castile soap every night, and afterward to dry the face by a vig- 
orous rubbing with a rough towel. Fere has asserted that the 
maintenance of intestinal antisepsis by the use of naphthol or salol 
will prevent the development of acne and digestive disorder when 
the bromides are given. 

Contraindications. — The bromides are contraindictated wherever 
there is general asthenia and feebleness of the nervous system, as, for 
example, in post-typhoidal and post-puerperal insanity. In senile 
softening of the brain they are also harmful. When the mucous 
membrane of the gastro-intestinal tract is irritated, they do harm. 
When the patient is subject to acne, they should be used with caution 
or avoided. 

Bromide of Ammonium. 

(See Ammonium Bromide.) 

Bromide of Calcium. 

Calcium Bromide (Calcii Bromidum, U. S.) was introduced into 
medicine as a nervous sedative and hypnotic, and was thought at one 
time to be an efficient substitute for the bromide of potassium. Its 
action on the nervous system is virtually identical with that of the 
potassium salt, and it has been found to be far less irritant and depres- 
sant than the latter. For some unknown reason it has never won the 
confidence of the profession, but it may be given with very good results 
in the dose of from 30 to 90 grains (2.0-6.0) a day, or even more in 
cases which are not readily effected by bromides. It may be employed 

1 See Collective Investigation by author in the Therapeutic Gazette of June 15, 1897; 
also article on Epilepsy, Part IV. 



BROMIDES. 157 

in hysteria and epilepsy and in all the conditions in which the other 
bromide salts are indicated. It is sometimes of value combined with 
the potassium salt, since under such circumstances better results are 
gained than if a single salt is employed. 



Bromide of Gold. 

The Bromide of Gold has been employed in epilepsy by a number 
of clinicians with great success in the dose of from } to J grain (0.012- 
0.03) three times a day in pills. Physiological studies have proved 
that the drug is a direct sedative to the motor cells in the cortex 
cerebri. 

Bromide of Lithium. 

Bromide of Lithium (Lifhii Bromidum, U. S.) is much weaker 
than the other salts, and must be given in larger dose. S. Weir 
Mitchell states that it is of value in epilepsy when the potassium salt 
fails. The dose is 30 to 90 grains (2.0-6.6) a day. 



Bromide of Nickel. 

Bromide of Nickel is a green salt quite irritant to the stomach. 
The author has made an experimental study of this salt and found 
it practically identical with the bromide of potassium in physiological 
action. It should be given well diluted or in an effervescing draught 
as it is apt to disorder the stomach if used in concentrated solution 
The effervescing form of the drug is made by mixing the salt with 
bicarbonate of sodium and tartaric acid, moistening with alcohol, 
passing the moist powder through a sieve, and then drying it in a 
warm closet. 

Bromide of Sodium. 

Bromide of Sodium (Sodii Bromidum, U. S. and B. P.) is to be 
used in every instance where bromide of potassium can be employed. 
Its dose is the same, although it is asserted to be a little weaker 
physiologically, grain for grain, than the potassium salt. It is far 
less apt to disorder the stomach, and is not so generally depressant 
as is the bromide of potassium. 

Bromide of Strontium. 

See Strontium. 



158 DRUGS. 

Hydrobromic Acid. 

Hydrobromic Acid is an extremely irritant preparation, but is 
thought to be less apt to cause acne and other untoward effects than 
the others bromides. It is only to be used in the form of the official 
dilute acid (Acidum Hydrobromicum Dilutum, U. S. and B. P.), and 
to be given in the dose of from 1 drachm to J ounce (4.0-15.0), 15 
to 60 minims (1.0—4.0), B. P., well diluted with sweetened water. 
It is highly recommeuded by de Schweinitz and others for headaches 
due to eye-strain in nervous women/ 

Bromide of Ethyl. 
See Ethyl Bromide. 

BROMINE. 

Bromum is a dark red liquid of an excessively pungent odor, 
like that of chlorine, possessing extraordinary power as a caustic 
when applied to the tissues of the body. It is the most severe 
caustic we possess, and penetrates very deeply. It may be applied 
in hospital gangrene and other large sloughs by means of a glass rod. 
Bromine should be kept in glass-stoppered bottles in a cool place. 

BROMOFORM. 

Bromoformum (U. S.) or Tribromomethane, is a clear, colorless 
liquid having a peculiar odor and sweet taste, consisting of 96 per 
cent, of absolute bromoform and 4 per cent, of absolute alcohol. It 
is readily soluble in alcohol, but slightly so in water. Bromoform 
which is to be used medicinally should be protected from sunlight 
and air, and must be free from color and from acid. 

Therapeutics. — Although bromoform has been found capable of 
producing anaesthesia when given by inhalation, its employment is 
confined to the treatment of whooping-cough, in the dose of 1 to 5 
minims (0.1-0.3) three times a day for the relief of the spasmodic 
cough. It may be put in a teaspoonful of syrup and mixed at the 
moment of taking. Bedford has suggested the following formula for 
its internal use : 

1$ — Bromoformi TTlxvj (1.0). 

Alcoholis f3ij (8.0). 

Glycerini f3xij (45.0). 

Tincturae cardamomi composite q. s. ad fgij (60.0). — M. 
S. — Teaspoonful (4.0) t. i. d. in water. 

This prescription should be compounded by adding the ingredients 
in the order named. 

Bromoform tends to depress the vasomotor system, but does not 



BUCHU. 159 



seem to depress the heart itself. While it seems to possess therapeutic 
value, the large number of cases reported in which it has caused 
alarming symptoms has prevented the author from employing it. 



BRYONIA OR BRYONY. 

Bryonia is a remedy very largely used by irregular physicians, and is 
probably too much ignored by reputable physicians, for it possesses very 
great power, and sometimes relieves conditions which are obstinately 
persistent under other treatment. It is the root of Bryonia alba or 
Bryonia dioica. The preparation commonly employed is the tincture 
( Tinctura Bryonke). The dose of the powdered root as a drastic purge 
is 10 to 40 grains (0.6-2.6). 

Physiological Action. — In overdoses bryonia acts as a hydragogue 
cathartic and gastrointestinal irritant. On serous membranes it 
exercises an irritant influence, aud may produce symptoms of menin- 
gitis when given in poisonous doses. In moderate doses bryonia 
causes some flushing of the face and neck and headache in susceptible 
persons. The drug needs studying from a pharmacological point of 
view. 

Therapeutics. — Although one of the oldest of remedies, bryonia has 
been given a new impetus by the homoeopaths, who employ it in a 
number of affections. In the treatment of dyspepsia depending upon 
gastric and intestinal atony bryonia often gives relief. Its influence is 
exerted through the irritant effects it produces, for by this means it 
stimulates or spurs the atonic digestive glands to increased activity. 
For this reason it has been found particularly useful in children who 
suffer from constipation resulting from insufficient secretion on the part 
of the intestinal glands. "When the passages are dry and friable and 
resemble in character those of a dog, bryonia is of great value. The 
dose for a child is about 10 to 30 minims (0.60-2.0). The drug has 
beeu praised as a remedy in the treatment of rheumatism and in 
pleurisy, but little is recorded as to its real value in these diseases. In 
pleurisy with effusion drastic doses have been used, but the saline purga- 
tives are safer and more efficacious remedies. 

Administration. — The dose of the tincture of bryonia (Tindura 
Bryonies) is from 1 to 2 fluidrachms (4.0-8.0) as a laxative ; but the 
so-called mother-tincture of the homoeopaths is perhaps the best pre- 
paration for ordinary use. The proper amount to be used in the treat- 
ment of a case of dyspepsia is from 5 to 40 minims (0-3-2.6), unless 
the mucous membranes are very torpid, when this quantity may be 
increased. 

BUCHU. 

Buchu (U. S.) is the dried leaves of Barosma betulina, a plant of 
Africa. It contains a volatile oil, which is probably the active princi- 



160 DRUGS. 

pie, and a bitter extractive. It is official, under the name of Buchu 
Folia, in the B. P. 

Therapeutics. — Buchu is used when it is desired to affect the mucous 
membranes of the gen i to-urinary tract which are chronically diseased, 
and particularly when these parts are below their normal tone. It 
does not increase the urinary flow to any great extent, but acts on the 
mucous membrane of the genito-urinary passages as a stimulant. It 
is employed in pyelitis, cystitis and vesical irritation of a chronic type. 
The following prescription is useful : 

R— Potassii citratis 5iv (16.0) 

Spiritus chloroformi f^iij (12.0). 

Tincturae digitalis TTlxxx (2.0). 

Infusi buchu q. s. ad fgviij (240.0).— M. 

S— Two tablespoonfuls (30.0) three times a day. Shake the bottle before using 

If the urine is continually highly acid, muddy, laden with salts, 
and productive of incontinence by reason of the vesical irritation 
which it produces, buchu in the form of the fluidextract, in the dose 
of a teaspoonful (4.0) three times a day, combined with an equal amount 
of sweet spirit of nitre and 20 grains (1.3) of acetate of potassium will 
be of great service. For a child the dose of the fluidextract should be 
about 10 to 30 minims (0.9-2.0). If the vesical irritation is acute, 
buchu is contraindicated. 

Administration — The fluidextract (Fluidextr actum Buchu, U. S.) is 
the only official preparation, and it should be always well diluted 
before it is given, in the dose, to an adult, of 1 drachm (4.0) three 
times a day. The infusion is not official, but is made by adding 1 
ounce (30.0) of the leaves to a pint (480 mils.) of water. The dose 
of this is J ounce (16.0) to 1 ounce (30.0). The official B. P. prepara- 
tions are the infusion (Infusum Buchu), dose 1 to 2 fluidounces (30.0- 
60.0), and the tincture (Tinctura Buchu), dose J to 1 fluidrachm 
(2.0-4.0). 

CACTUS GRANDIFLORUS, 

This is a plant of Mexico and the West Indies. There are other 
species of Cactus possessing medicinal power, but Cactus grandiflorus 
is said to be the most active so far as a medicinal effect upon the heart 
is concerned. 

Cactus grandiflorus is best given in the form of the tincture or the 
fluidextract made from the green plant, 

Physiological Action. — The drug has been studied by Myers and 
Boinet and Teissier, who assert that it causes a distinct increase of 
arterial pressure, but does not slow the pulse, sometimes increasing its 
rapidity. According to Sayre and Houghton, however, it is not pos- 
sessed of much power, and their conclusions have been proved correct 

by others. 

Therapeutics. — Cactus grandiflorus has been used as a remedy for 
cardiac palpitation and weakness, but it is a very feeble remedy. 



CAFFEINE. 



161 



Administration. — The dose of the tincture of cactus is 2 to 8 minims 
(0.1-0.5) and of the fluidextract 2 to 4 minims (0.1-0.25). 



CAFFEINE. 1 

Caffeine (Caffeina, U. S. and B. P.) is an alkaloid derived from Thea 
Camellia and the berries of Caffea Arabia, which also contain, upon 
roasting, an empyreumatic oil, caffeol or caffeone. Caffeine occurs as 
white, flexible, silky, glistening 
needles, usually matted together fig. 19. 

in fleecy masses, permanent in the 
air; odorless and having a bitter 
taste. If crystallized from water, 
it contains one molecule of water 
of crystallization, but if it is crys- 
tallized from alcohol, chloroform, 
or ether it contains none. It is 
soluble in 46 parts of water, 66 
parts of alcohol, 530 parts of 
ether, and 5.5 parts of chloroform 
at 25° C. (77° F.); soluble in 5.5 
parts of water at 80° C. (176° 
F.), and in 22 parts of alcohol at 
60° C. (140° F.). Its solubility 
in water is increased by the pres- 
ence of certain salts — e. g., po- 
tassium bromide, sodium ben- 
zoate, sodium salicylate, and 
others. 

Caffeine is usually employed in 
medicine as caffeine and the ci- 
trated caffeine (Caffeina Citrata, U. 
S.; Caffeinoe Citras, B. P.). Ci- 
trated caffeine is not regarded by 
chemists as a chemical compound, 
but as a mixture of citric acid 
and caffeine; therefore " citrate 
of caffeine" is an incorrect term. 

It occurs as a white powder, odorless, having a slightly bitter, acid 
taste and an acid reaction. One part of citrated caffeine forms a 
clear, syrupy solution with about 4 parts of hot water. If more 
water is added it is partly precipitated, but when 25 parts are added 
it is redissolved. In the U. S. P. another official preparation of caf- 
feine, the Caffeina Citrata Effervescens (Caffeina? Citras Effervescens, 




^^r 



Caffeine dilates bloodvessels of the Mal- 
pighian tuft and stimulates the secreting epi- 
thelium lining the uriniferous tubules. 



1 Theine derived from tea, caffeine, the active principle of coffee, and the alkaloid of 
guarana from South America, are chemically identical. All of the caffeine of com- 
merce is really theine, although it is claimed that pure theine has a very different 
physiological action. 
11 



162 DRUGS. 

B. P.), has been introduced as an agreeable preparation for use in 
cases of headache, particularly if combined with one of the bromides 
and antipyrine. The dose is from J to 2 drachma (2.0-8.0) in water. 

The empyreumatic oil, of which there is about one-half to one tea- 
spoonful in each well-made breakfast cup of coffee, has no physio- 
logical effects. It is perhaps the cause of the " biliousness" sometimes 
produced by the habitual use of coffee, due to the faulty digestion of 
this oil, which is also prone to disorder the digestion if taken alone. 

Physiological Action. — Nervous System. — On the nervous system 
caffeine acts as a rapidly-acting stimulant, exerting its chief influence 
on the brain and spinal cord. By its cerebral effect it causes increased 
rapidity of thought, and by its influence on the spinal cord it increases 
reflex activity, and for this reason is said to make people "nervous." 
It is important to remember that it has no effect on brain protoplasm 
except to increase its functional activity. Caffeine does not produce 
cerebral exhaustion unless it is taken in such a manner and such large 
doses as to interfere with sleep, rest, and the taking of food in ordinary 
quantities. Hollingworth has shown that an individual is enabled to 
do more mental work in a given space of time with caffeine than he 
is capable of doing without it, and that this increased work is not 
followed by depression or exhaustion. In other words, it acts as a 
lubricant does in machinery, increasing ability without causing 
exhaustion. H. C. Wood, Jr., has shown that it acts on the muscles 
in a similar manner, and Farr's studies on urinary output fail to show 
that it causes an evidence of increased muscle break-down. 

Hektoen and Le Count have shown that the continual use of caffeine 
in doses such as are commonly found in tea and coffee produce no 
lesions in any tissues of the body. 

Circulation. — Caffeine has been supposed to increase the pulse- 
rate and blood-pressure by stimulating the heart-muscle, but from 
recent studies in the United States and abroad it would seem prob- 
able that these changes are indirectly produced and due chiefly to its 
stimulating action on the nervous system. Clinically, it certainly 
seems to raise the blood-pressure in many instances of low pressure. 

Kidneys, Tissue-waste, and Elimination. — Caffeine increases 
diuresis by causing dilatation of the renal vessels, particularly in the 
glomerules, and by preventing the absorbent action of the tubules. It 
also exerts a direct stimulating influence on the secretory epithelium 
of the kidney, and therefore increases the amount of solids as well as 
of the liquids in the urine. Upon tissue-waste the drug acts as a 
depressant, and is therefore a conservator of the tissues. It is oxidized 
and destroyed in the body. 

Respiration. — Caffeine acts as a valuable stimulant to the respira- 
tory centre. 

Therapeutics — Caffeine is a valuable cardiac stimulant and tonic as 
well as a renal stimulant. It acts equally well in cardiac and renal 
dropsies for this reason, and is an invaluable remedy in such cases. So 
useful is caffeine in cases of cardiac disease that it has largely supplanted 



CAFFEINE. 163 

digitalis in the hands of some practitioners, but its action is so differ- 
ent from that of foxglove that it cannot be considered in the same class 
of stimulants. In. acute renal inflammation it is contraindicated, 
because all stimulants are contraindicated when the part they influ- 
ence is inflamed. In opium-poisoning, owing to its stimulant effect 
on the respiratory centre, caffeine is very valuable. It may be given 
by the mouth or rectum in the form of strong black coffee, which 
will also aid in keeping the patient awake and add heat to the body, 
which is often very cold, or by the hypodermic needle. A cup of 
strong black coffee is often useful in relieving a paroxysm of asthma. 
In headache due to nerve-strain caffeine combined with antipyrine 
or acetphenetidin, and one of the bromides, is often of the greatest 
service. (See Bromide of Potassium and Neuralgia.) 

Roasted coffee is sometimes used to mask the taste of disagreeable 
medicine. After it is roasted and ground it may be employed as an 
antiseptic and deodorant dressing for wounds when the common anti- 
septics are not obtainable. 

Administration. — The ordinary dose of caffeine is 2 to 4 grains (0.12- 
0.25). 

Caffeina, U. S. and B. P., cannot be used hypodermically, owing to its 
decomposition in the presence of water. The following solution may, 
however, be used hypodermically : Salicylate of sodium, 30 parts; caf- 
feine, 40 parts ; and distilled water, 60 parts ; or, in other instances, the 
following preparation, recommended by Huchard, may be employed : 
Benzoate of sodium, 45 grains; caffeine, 30 grains ; distilled water, 75 
grains. This mixture is to be heated, and 10 minims (0.60) given at 
a dose. An excellent formula which can be used hypodermically com- 
bining the stimulant properties of caffeine and camphor is as follows : 

]$ — Caffeinae, 

Sodii salicylates aa g.iv 

Aquae destillatae 1U xv 

Misce.et adde 

Spiritus camphorae (10 per cent.) . . . . HI xv 
It is asserted that this formula when made remains clear for a long time. 

The new U. S. P. has made Caffeina Sodio-benzoas official for this 
purpose. 

Untoward Effects. — Caffeine often produces so much insomnia when 
given in full doses in cases of cardiac disease that its use has to be 
discontinued. If its use is persisted in, it may produce a condition 
of delirium closely resembling that of alcoholism. The writer has 
also seen a marked rise of temperature in a patient follow its use in 
the doses of 2 grains (0.12) three times a day, but this is unusual. 
In certain persons the habitual use of coffee in excess in the presence 
of overwork and lack of sufficient rest and food may result in insomnia, 
tremors, palpitation, tinnitus aurium, gastralgia, and emaciation. 



164 DRUGS. 



CAJTTPUT OIL. 



Oil of Cajuput {Oleum Cajuputi, U. S. and B. P.) is a volatile oil 
distilled from Melaleuca Leucodendron, a tree of the Molucca Islands. 
It is a stimulant, and in large amounts an irritant, to mucous mem- 
branes, but acts as an efficient carminative and parasiticide in mod- 
erate amounts. As a remedy for tinea tonsurans and pedicuU it should 
be applied pure to the part affected and used with caution, for cajuput 
oil is capable of irritating the skin. In diarrha?a of a serous type it 
is of value in the dose of 10 to 20 minims (0.60-1.30), J to 3 min- 
ims (0.03-0.18), B. P. (See Diarrhoea.) Spiritus Cajuputi is offi- 
cial in the B. P. ; dose 5 to 20 minims (0.3-1.2). 

CALCIUM. 

Calcium is official in a number of forms, and is to be distinctly 
separated in the mind of the student from calx or lime, which is an 
oxide of calcium. It is never employed as calcium, but as one of its 
salts. These are as follows : bromide of calcium (Calcii Bromidum, 
U. S.) ; precipitated carbonate of calcium (Calcii Carbonas Prazcipi- 
tatus, U. S. and B. P.) ; chloride of calcium (Calcii Chloridum, U. S. 
and B. P.) hypophosphite of calcium (Calcii Hypophosphis, U. S. and 
B. P.) ; and as precipitated phosphate of calcium (Calcii Phosphas 
Pmcipitatus; Calcii Phosphas, B. P.; Calcii Glycerophosphas, U. S., 
and Calcii Lactas, U. S.). Calcium sulphate is official in the B. P. 

All salts of calcium are incompatible with acids. 

Carbonate of Calcium. 

The precipitated carbonate (Calcii Carbonas Pracipitatus, U. S. and 
B. P.) of calcium is used in the treatment of serous diarrhoea as an 
antacid and as a local protective in cases of chapped skin or intertrigo, 
particularly in young children. When given internally the dose is 
from 10 to 30 grains (0.6-2.0). 

Precipitated carbonate of calcium is the slowest acting antacid which 
we possess, and for this reason the remedy is to be employed in acidity 
of the intestines, as it passes through the stomach to a very great 
extent unchanged. (For the varieties of diarrhoea in which it is to be 
used see article on Diarrhoea.) As an external application it is used in 
sweating of the feet and hands, and sometimes as a dry dressing to 
ulcers. It may also be used over burns. 

Chalk. — Chalk is a native calcium carbonate, chiefly obtained 
from shells. 

Prepared chalk {Cretan Pmparata, U. S. and B. P.) is given in the 
dose of 20 to 60 grains (1.3-4.0). By far the best method for its 
administration is in the employment of chalk mixture (Mistura Cretan, 
U. S. and B. P.), which contains about 30 grains of the chalk to each 



CALCIUM. 165 

ounce (2.0-30.0) of liquid. The dose of this mixture is from 1 drachm 
(4.0) for a young child to an ounce (30.0) for an adult. In the treat- 
ment of cases of serous diarrhoea chalk mixture is best given in com- 
bination with tincture of kino or the compound tincture of gambir and 
paregoric, in some such form as follows : 

3— Tincturse kino 5J (30.0). 

Tincturae gambir compositi f5ij (8.0). 

Misturae creta? q. s. ad fgvj (180.0).— M. 

S.— A dessertspoonful (8.0) every three hours until diarrhoea ceases. 

It is to be remembered that the chalk mixture acts very slightly as 
an astringent, and chiefly as an antacid and mechanical agent in the 
alimentary canal. 

Chalk made into a paste may be used as a substitute for bismuth 
paste in the treatment of sinuses. (See Bismuth.) 

Other preparations are compound chalk powder (Pufais Cretoe Oom- 
positus, U. S.), composed of prepared chalk, acacia, and sugar, and 
given in the dose of 10 to 60 grains (0.60-4.0), and troches of 
chalk (Trochisci Or eke). Preparations official in the B. P., but not 
in the U. S. P., are aromatic powder of chalk \Pulvis Or eke Aro- 
maticus), dose 10 to 60 grains (0.60-4.0), and Putt's Oreim Aromaticus 
cum Opio, dose 10 to 40 grains (0.60-2.4). 

Calcium Chloride and Lactate. 

Calcium chloride (Oalcii Ohloridum, U.S. and B.P.)when taken inter- 
nally in large amount acts as an intense gastro-intestinal irritant, and may 
produce death by this means. It is to be distinctly separated from the 
chlorinate, or chloride, of lime, with which it is sometimes confused, 
for the latter is hydrate of lime or slaked lime, containing 30 per cent, 
of chlorine, while chloride of calcium is a hard, vitreous, friable sub- 
stance, giving off no odor of chlorine and utterly different in its use, 
action, and appearance. 

In cases where boils mature slowly a poultice made by adding a 
solution of chloride of calcium to the mass may be used to hasten 
suppuration. 

Another use of calcium chloride, which is worthy of trial, is its 
employment in the treatment of itching. It should be given in the 
dose of 20 grains (1.3) three times a day to an adult and may be pre- 
scribed as follows: 

Ifc— Calcii chloridi 5ij (8.0). 

Tincturse aurantii f5vj (24.0). 

Aquae chlorofnrmi q. s, ad fgvj (180.0). — M. 

S. — One or two tablespocnfuls (16.0-30.0) three times a day. 

Smaller doses may be needed if the stomach is irritable. These 
doses usually produce some thirst. They should be taken about one 
hour after a meal. 



166 DRUGS. 

Small doses of calcium chloride have also been used to increase the 
coagulability of the blood in " bleeders" and to prevent attacks of urti- 
caria by an influence on the blood-plasma, particularly in those cases 
in which the state of the blood has been altered by the ingestion of acid 
fruits. When used the dose should be 20 grains (1.3) three times a 
day. Unfortunately, as already stated, it is apt to disorder the stom- 
ach. A better preparation for this purpose is calcium lactate (Calcii 
Lactas, U. S. and B. P.). Calcium chloride, or lactate, may also 
be used to relieve albuminuria, which is not dependent upon organic 
disease of the kidneys but to conditions in the blood which permit 
an escape of albumin through the renal bloodvessels. Indeed, its 
ability to control so-called physiological albuminuria may permit us 
to use it to differentiate albuminuria due to organic renal disease, 
which it cannot control, from that type called "functional." The 
effect of the drug upon bleeding and albuminuria is usually mani- 
fested within an hour or two and persists for several days. An 
important point to be remembered is that the too prolonged admin- 
istration of calcium decreases rather than increases the coagulability 
of the blood. The use of the drug should therefore be stopped for 
several days after it has been taken for 6 or 8 doses. It is also 
important to remember that some cases of haemophilia or purpura 
seem unable to absorb the calcium salts from the alimentary canal. 
Such cases should be treated by the use of calcium lactate hypo- 
dermically, the solution of which should not be stronger than 1 to 
20 of water. Calcium chloride is too irritating for hypodermic use. 
Addis has seemed to prove that it is not possible to shorten coagu- 
lation time by the use of calcium salts. The question as to their 
employment for this purpose is therefore sub judice, the more so as 
it is becoming more and more evident that as the blood contains a 
very small amount of calcium and can always get all it needs from 
the bones. Ross has reported the successful use of calcium chloride 
and lactate, when given by the mouth, in cases of persistent dull 
headache associated with heaviness, listlessness, a lymphatic tempera- 
ment, and decreased coagulability of the blood. 

Very large doses of the calcium salts have recently been recom- 
mended for the relief of persons suffering from tetany due to disease 
or injury of the parathyroid glands and for the tetany of lactation and 
pregnancy by W. G. MacCallum and Voegtlin. 

Calcium Hypophosphite and Precipitated Calcium Phosphate. 

The hypophosphite of calcium and the precipitated phosphate of 
calcium are used for the treatment of scrofulous or strumous states 
and allied conditions, such as rachitis, generally in the form of the 
Syrupus Hypophosphitum, U. S., and the Syrupus Calcii Lacto- 
phosphatis, U. S. and B. P. 

The large amount of phosphate of calcium normally present in the 
bones and tissues renders it a useful drug when the body is starved 



CALUMBA. 167 

of its proper proportion of salts, and its use has been found, in animals, 
to cause a great increase in bony growth, not only in the earthy, but 
also in the animal, constituents of the osseous tissues. The hypo- 
phosphite has a similar effect. 

In rickets and in fractures where the bone is slow in uniting, and 
in some cases of phthisis and scrofula, the lactophosphates and hypo- 
phosphites have been thought to be of service. 

It is worthy of note that these salts are of little value in tubercu- 
losis after it is well developed. They do good, if at all, in the so-called 
pretubercular or beginning stages of the disease ; and the good effects 
of the so-called syrups of the hypophosphites depend more upon the 
other ingredients present in them than upon the calcium salts they 
contain. In dental caries particularly that occurring in nursing 
women they are useful. 

The lactophosphates are better than the hypophosphites, as the 
latter are probably changed into phosphates in the stomach as soon 
as they enter that viscus. The dose of either the lactophosphates or 
the hypophosphites is 10 to 30 grains (0.60-2.0) three times a day, or 
of the syrups just named a teaspoonful to a tablespoonful (4.0-16.0). 
The difference between these salts and phosphorus, both in thera- 
peutical effect and in physiological action, is to be clearly borne in 
mind. The lactophosphates and hypophosphites are simply con- 
venient modes of administering calcium, potassium, or other substances, 
while phosphorus acts as a stimulant to bone-growth, and not by its 
deposition in the bone. Phosphoric acid does not act any more like 
phosphorus than does sulphuric acid act like sulphur. 

Sulphate of calcium is not to be confounded with calx sulphurata, 
often wrongly called sulphide of calcium. (See Boils and Calx.) 



CALUMBA. 

Calumba (U. S.), Calumbce Radix (B. P.). Columbo, or Columba. 
is the root of JateorrJiiza Palmata. Its taste is bitter and its color 
is sli^htlv aromatic. Two alkaloids are found in it, berberine and 
columbine, and a third substance known as calumbic acid. Calumba 
is one of the purest bitters known, as it does not contain tannic acid,, 

Therapeutics. — Calumba is one of the best simple tonics that can 
be used, owing to its lack of astringent effect and to its favorable 
action on mucous membranes. 

In cases of gastro-intestincd atony, particularly that following fevers 
and similar states, calumba will be found of service, and it is a val- 
uable remedy in the convalescent stages of summer complaint and 
serous diarrhoeas. The following prescription of Dr. George B. Wood 
is very useful in intestinal atony when associated with flatulence, 
although its bulk is disadvantageous and its taste bitter: 



168 DRUGS. 

]$ — Pulveris calumbse gss (16.0). 

Pulveris zingiberis gss (16.0). 

Sennse foliorum §j (4.0). 

Aquae bullientis ........ Oj (480 mils.). — M. 

Fiat infusum. 

S. — A wineglassful t. i. d. 

Administration. — The fluidextract {Fluidextractum Calumbce) is 
given in the dose of 15 to 60 minims (1.0-4.0) ; the tincture (Tinctura 
Calumbce, U. S. and B. P.), dose | to 2 fluidrachms (2.0-8.0 mils.). 
The dose of the infusion Infusum Calumbce, B. P., is \ to 1 fluid- 
ounce (16.0-30.0). Liquor Calumbce Concentratus, B. P., is given in 
the dose of J to 1 drachm (2.0-4.0). 

CALX. 

Calx (U. S. and B. P.), or Lime, or Oxide of Calcium, is an alka- 
line earth which is incompatible with acids, ammoniacal and metallic 
bases, borates, alkaline carbonates, and astringent vegetable infusions. 
It is prepared by calcining white marble, or the purest varieties of 
native calcium carbonate, and contains, when in the anhydrous state, 
not less than 90 per cent, of pure calcium oxide. It should be kept 
in well-closed vessels, in a dry place. It occurs as hard, white, or 
grayish-white masses, which in contact with the air, gradually attract 
moisture and carbon dioxide, and fall to a white powder ; which is 
odorless, and has a caustic taste. It is soluble in about 840 parts of 
water at 25° C. (77° F.), and in about 1740 parts of boiling water; 
It is insoluble in alcohol. It forms readily soluble salts with diluted 
acetic, hydrochloric, or nitric acids. When sprinkled with about 
half its weight of water, calcium oxide becomes heated, and is 
gradually converted into a white powder (calcium hydroxide or 
slaked lime). When this is mixed with about 3 or 4 parts of water, 
it forms a smooth magma (milk of lime). 

Therapeutics.- — Lime is used for the purpose of acting as an eschar- 
otic, particularly on old ulcers and on hairy growths. It is never 
given internally except in the form of the hydrate, or slaked lime. 
As an escharotic application lime is used in the caustic Potassa, 
cum Calce. When given internally it should always be used as 
Liquor Calcis, U. S. and B. P., or lime-water, and under these cir- 
cumstances it acts as an antacid, as an aid to the digestion of milk 
by preventing too rapid and solid coagulation of the casein, and by 
exciting an increased gastric secretion. It is also feebly astringent. 
Given to infants and nursing women, it is probably utilized in the 
body in the formation of bone. It is also of value in diabetes, in the 
uric-acid diathesis, and in the excessive nausea and vomiting often seen 
in adults and children and due to acidity of the stomach. Teaspoon- 
ful doses of milk and lime-water, equal parts, will often be retained 
by such patients when nothing else will remain in the stomach. 



CALX CHLORINATA. 169 

The dose of lime-water is 1 drachm (4.0) to 1 ounce or even 2 ounces 
(30.0-60.0). Externally applied, lime-water is of value in tinea capitis 
and similar states, and was at one time a popular application in burns, 
when mixed with equal parts of linseed or olive oil, forming Linimen- 
tum Calcis, U. S. and B. P., or Carron oil. Picric acid is much better. 
(See Burns, Part IV.) As a local application in membranous croup 
and diphtheria lime-water has had a high reputation, and is believed to 
dissolve the membrane, but it does not compare in usefulness with per- 
oxide of hydrogen. It may be used as a spray or by means of a swab. 

Liquor Calcis, U. S. or lime water, is to be made by adding a piece 
of unslaked lime as large as a walnut to 2 quarts of boiled and filtered 
water in an earthen jar ; after stirring it thoroughly allow it to settle, 
and pour on the clear liquid into a bottle. More water may then be 
added to the lime until it is all used. 

Calx Chlorinata. 

Chlorinated lime (Calx Chlorinata, U. S. and B. P.) is the hy- 
drate of lime, containing 30 per cent, of chlorine, provided it is of 
official strength. It is an exceedingly irritant substance because of 
the chlorine which it contains, and is never used internally. It 
occurs as a white, or grayish- white, granular powder, exhaling the odor 
of hypochlorous acid, having a repulsive, saline taste, and becoming 
moist and gradually decomposing on exposure to air. 

In water or in alcohol it is only partially soluble. 

Much of the chlorinated lime sold is useless, containing too little 
or no free chlorine. Good chlorinated lime should be so laden with 
the gas that the face cannot be held near it without the eyes being 
severely irritated. Unless the chlorine is present, the lime is of 
no value, for the employment of chlorinated lime as a disinfectant 
depends upon the action of this gas, the lime being used merely as a 
vehicle and oxidizer, the gas by itself being difficult of application. 

As a disinfectant for privies, drains, and sinks chlorinated lime 
is one of the best, if not the best, we possess. A few pounds of it 
may be added every week to the contents of a privy vault with great 
advantage, and a solution of it may be used in bed-pans and urinals. 
When the passages of a patient having typhoid fever are to be 
received in a bed-pan, a chlorinated-lime solution should be placed 
in the receptacle beforehand, so that the fecal matter or urine will 
fall at once into a disinfecting fluid, when the contents of the pan 
should be well mixed. The solution should be of the strength of 
1 pound to 2 gallons. Chlorinated lime should be placed liberally 
over and about decaying animals, and in exhuming corpses sheets 
wrung out in a solution made as directed above will, if wrapped 
about the body, be found of service to destroy the stench. 

Chlorinated lime, in the proportion of a level teaspoonf ul, rubbed up 
in a cup of water, and then diluted with three cupfuls of water, may 



170 DRUGS. 

be used to purify and disinfect germ-laden water in the proportion of 
one teaspoonful of this solution to 2 gallons. This produces no dis- 
agreeable taste in the water, as the proportion of free chlorine is only 
4 to 5 parts in a million, but it is sufficient to destroy in ten minutes 
typhoid and cholera bacilli and the dysentery bacillus. 

Thresh advises that in no case should less than 1 part of chlorine 
be added to 1,000,000 parts of water, and if the water is known to 
be foul, as when derived from a polluted river, 2, 3 or more parts 
should be added. His method is as follows: 

1. Obtain a supply of high quality chlorinated lime in J-pound 
hermetically sealed tins. 

2. A corresponding number of J-pound packets of sodium thio- 
sulphate. This salt (usually called hyposulphate of soda and largely 
used in photography) is nearly tasteless and combines with all the 
available chlorine in about half its weight of chlorinated lime. From 
these the following stock can Le quickly prepared: 

3. Add the contents of a tin of No. 1 to 1 gallon of water and 
shake until uniformly mixed. 

4. Add one packet of thiosulphate to 1 gallon of water and shake 
until dissolved. 

A gallon of solution No. 3 will sterilize 8000 gallons of any 
ordinary clear well or river water in fifteen minutes, and if at the 
expiration of that time the 1 gallon of thiosulphate solution No. 4 be 
added to the water any excess of chlorine will be eliminated. 

If calcium hypochlorite is obtainable it may be substituted; 15 
grains (1.0) will sterilize 40 gallons of water in half an hour. 

Chlorine fumes will bleach many dyed goods, and therefore colored 
fabrics should not be exposed to them. 

Chlorine gas, in a diluted form, has been used for the treatment of 
aphonia due to cold in cases where the aphonia persists for some 
weeks. It can be liberated by allowing a few drops of hydrochloric 
acid to fall upon chloride of lime or chloride of sodium. 

The placing of chlorinated lime in saucers about sinks and closets 
for the purposes of disinfection is useless. 

When the chlorine is present in a sufficiently concentrated form to 
kill germs, it will also kill the occupant of the chamber. A deodo- 
rant effect may be obtained, but a bad smell, if it exists, even when 
overcome by a greater one, is not really gotten rid of. 

The official preparations of the B. P. are Liquor Calcis Chlorinate 
and Vapor Chlori. 

Calx Sulphurata. 

Sulphurated lime (Calcii Sulphidum Crudum,JJ. S., Calx Sulphurata, 
B. P.) is useful to check inflammation and hasten suppuration; the 
dose is | to J grain (0.015-0.03). It is of great value in acne pustulosa 
and all forms of cutaneous suppuration. When sulphurate of lime is 
not obtainable and successive crops of boils appear it is often possible 



CAMPHOR. 171 

to relieve the patient by baking eggs-shells in an oven, powdering 
them, and then letting the patient eat 1 drachm (4.0) or more of the 
powder each day. 

The preparations of the B. P. that are not official in the U. S. are 
the saccharated solution of lime [Liquor Caleis Saccharatus), dose 15 
to 00 minims (1.0-4.0), and slaked slime (Calcii Hydras'), used in 
making different preparations. 

CAMPHOR. 

Camphor (Camphora U. S. and B. P.) is derived from Cinnamomum 
Camphora, which grows chiefly in China and Japan. The camphor 
used in the drug-stores is refined camphor, and is obtained by repeated 
sublimation. Camphor should be kept in well closed vessels, in a 
cool place. It occurs in white, translucent masses, of a tough con- 
sistence and a crystalline structure, readily pulverizable in the pres- 
ence of a little alcohol, ether, or chloroform ; having a penetrating, 
characteristic odor, and a pungent, aromatic taste. It is soluble in 
1000 parts of cold water and in 1 part of strong alcohol. Camphor 
is so volatile that if exposed to the air for any length of time it is 
wholly volatilized. It is an exceedingly combustible substance, 
burning with a smoky flame. It may be white or pinkish in color. 

Physiological Action. — If taken in very large doses, camphor pro- 
duces epileptiform convulsions, preceded by vertigo, roaring in the 
ears, and delirium. The pulse soon becomes rapid, feeble, and running, 
and the skin livid, cold, and covered with sweat. Intense heat and 
burning may be felt in the belly, and, if the poisoning be slow, evi- 
dences of gastro-intestinal and renal inflammation ensue. In small 
doses it acts as a stimulant and gives a sensation of warmth to the 
stomach, while the pulse may become more rapid and stronger under 
its influence. At the same time there is a sedation of the nervous 
system and a general feeling of contentment. In large medicinal 
dose camphor is thought by some, to act as a sexual stimulant, and 
by others as a sexual sedative. The stimulant effect is probably only 
produced by doses large enough to produce irritation of the genito- 
urinary tract. The convulsions following poisonous doses are due to 
the action of the drug on the brain. The drug, although largely 
destroyed in the body, is chiefly eliminated by the kidneys as campho- 
glycuric acid, and also escapes by the breath and the perspiration. 

Therapeutics. — Internal Use. — Camphor is employed for the 
purpose of acting as a nervous sedative and antispasmodic in the treat- 
ment of nervous women and children, and as a carminative in indi- 
viduals who suffer from intestinal flatulence. It is of value in nervous 
dysmenorrhea and headache, and is best combined with one of the 
new analgesics, such as antipyrine and acetanilide given in tablet form. 
As it is virtually a volatile oil so far as its physiological action is 
concerned, it will be found useful in cholera, and in cholera morbus,. 
and in all forms of serous diarrhoea, but rarely in mucous diarrhoea. 



172 DRUGS. 

(See Diarrhoea.) In chordee, combined with bromides and similar 
depressants to the spinal cord, camphor is of great service in some 
cases, particularly late in the disease. In adynamic fevers it has been 
used as a diffusible stimulant by Graves and by many others since 
his time with success. Camphor is a very useful remedy in sudden 
depression coming on in the course of acute and prolonged diseases, 
such as croupous pneumonia and typhoid fever. It may be given by 
the mouth or, if the emergency is a pressing one, by hypodermic in- 
jection. Under these circumstances it is best given in the dose of 
5 grains (0.4) dissolved in almond oil, which should be perfectly ster- 
ile. When used in the nervous depression of phthisis, Alexander 
asserts that its continuous injection may result in cumulative action 
and develop the symptoms of mild camphor poisoning; but experi- 
ence leads me to believe that very much larger doses than those 
hitherto considered wise are often efficient. In hiccough it is of 
great service, and in cardiac palpitation due to functional irrita- 
bility it is of value. In old or atonic cases of capillary bronchitis 
and catarrh of the air-passages it is useful. In chronic nasal catarrh 
spirit of camphor when inhaled from the mouth of a vial gives off 
enough of the drug to stimulate secretion and tone up the parts. It 
is also of value as a mouth-wash in persons who have fetid breath. 

Camphor may be inhaled or taken internally in cases of cold in the 
head, in the early stages, with great relief, and exercises a decided influ- 
ence in aborting the attack. The following formula may be employed : 

I$— Camphorse gr. v (0.33). 

Extracti belladonna? . . . gr. j (0.06). 

Quininae sulpliatis gr. x (0.65). — M. 

Fiant tabellas vel capsular No. x. 

S. — One every hour for four or five doses. 

After the attack is well developed this is useless, but used early it 
will decrease the frontal headache and the sneezing and running at 
the nose. In coryza from unknown causes with much lachrymation 
and incessant sneezing, camphor will be found of benefit. It may be 
snuffed up the nostril in a fine powder, or powdered camphor may 
be put in boiling water and fumes inhaled. The spirit may also 
be inhaled from a handkerchief. 

External, Use. — Externally camphor may be used as a stimulant 
to indolent sores and as a useful addition in small amount to the pre- 
cipitated carbonate of calcium as a dusting-powder in intertrigo. In 
the form of a liniment camphor is used over inflamed joints from 
sprains or rheumatism, and in myalgia and neuralgia to relieve the 
pain and stiffness. A mixture of camphor and phenol is a useful 
application to burns and small wounds. (See Phenol.) 

Camphorated alcohol, spirit of camphor, is a useful application for 
abortive purposes when used over boils in their early stages, if repeated 
two or three times a day for a few moments at a time. Following 
these applications, the skin should be dried and camphorated oil ap- 



CAMPHOR MONOBROMATE. 173 

plied. Ringer and Tilt recommend that Eau de Cologne, saturated 
with camphor, be rubbed into the scalp in the drowsiness and head- 
ache of the menopause, and a lotion of equal parts of aqua ammonise 
and spirit of camphor dabbed on the painful or hypersesthetic spots 
at the top of the head, so commonly felt by nervous women at the 
change of life or during menstruation, will be found to give relief. 

Administration. — Camphor is used internally in the form of the 
camphor- water {Aqua Camphoras, U. S. and B. P.), dose J to 2 fluid- 
ounces (16.0-60.0) ; the spirit of camphor (Spiritus Camphorce, U. S. 
and B. P.), dose \ fluidrachm (2.0), or in the form of the camphor 
itself, in pill, in the dose of 1 to 3 grains (0.06-0.20) in each pill. 

The best preparation for internal use is the spirit, or the camphor 
itself may be given in pill or capsule. 

For external use we have, official, camphor liniment (Linimentum 
CamphoroB, U. S. and B. P.) and soap liniment, or Linimentum 
Saponis, U. S. and B. P., which is the milder of the two. A com- 
pound tincture of camphor (Tinctura Camphorce Composita), 
composed of opium, benzoic acid, camphor, and oil of anise, is 
official in the B. P., dose 15 minims to 1 fluidrachm (1.0-4.0). This 
preparation is practically equivalent to "paregoric." (See Opium.) 
Linimentum CamphorcB Ammoniatum, B. P., is composed of camphor, 
rectified spirit, and stronger ammonia. 

CAMPHOR MONOBROMATE. 

Monobromated Camphor {C amphora Monobromata, U. S.) is made 
by heating together in a sealed tube camphor and bromine. It occurs 
in colorless crystals or scales, and has a mild taste resembling cam- 
phor. It is almost entirely insoluble in water, but is freely soluble 
in alcohol, ether, and chloroform. 

Physiological Action. — Monobromated camphor is thought to possess 
powers partaking of the bromides and of camphor, but most, if not all, 
of its effects are due to the camphor alone, because the bromide is 
present in too small an amount to exercise much, if any, effect; and, 
more important still, the bromine and the camphor form so stable a 
compound that they are not disassociated when absorbed. In the 
frog it causes, when given in poisonous dose, loss of reflex action, 
motor palsy and death by respiratory failure, and iD warm-blooded 
animals violent convulsions, Cheyne-Stokes respirations, muscular 
tremblings, and weakness. The pulse is at first more rapid than 
normal, then slow and weak, death ensuing in coma or during the 
convulsions. 

Therapeutics. — When combined with other drugs monobromated 
camphor will generally be found useful for pain, particularly in 
lumbago, or the pain due to nervous disturbances. If used in hys- 
terical females, it will often produce sleep, and is of value to those 
who are addicted to the alcohol-habit, as it acts as a sedative and 



174 DRUGS. 

warms the stomach. Like camphor itself, it is a gastric irritant, and 
should not be employed where gastritis exists. It has been used in 
spermatorrhoea with some success, and in delirium tremens has been 
found of benefit in cases where the gastric mucous membrane is 
depressed and the nervous twitchings are troublesome, but as a ner- 
vous sedative it is too feeble to control the patient's delirium. In 
whooping-cough it may be tried, and it has been used in chorea, 
epilepsy, and petit mal. In the nervous depression and pains of 
epidemic influenza monobromated camphor has been largely used. 
It is not of very great value. 

Administration. — This drug should never be used hypodermically, 
as it is too irritating, but administered in the dose of 5 grains (0.32*) 
three times a day in pill, or in an emulsion made by dissolving it in 
six times its weight of expressed oil of almonds arid then forming 
an emulsion with gum-arabic water in the usual manner. 

CAMPHORIC ACID. 

Acidum Camphoricum, made by the oxidation of camphor 
through the influence of acids, is the best remedy for the night-sweats oj 
phthisis. In a large number of cases suffering from night-sweats the au- 
thor has found this drug to act very favorably indeed where other reme- 
dies failed, and he has never seen it produce disagreeable symptoms. 

It may be given in the dose of from 20 to 30 grains (1.3-2.0), 
taken an hour or two before the sweat is expected. In very obsti- 
nate cases as much as 60 grains (4.0) should be given, but under 
these circumstances it should be used in two separate doses of 30 
grains (2.0) each, two hours apart, in order to avoid irritating the 
stomach. It is best given in capsule or cachet, as it is insoluble in 
water. In other instances camphoric acid may be given in the fol- 
lowing formula : 

I$— Acidi camphorici 3iv (16.00) 

Alcoholis fgij (60.0). 

Mucilaginis acaciss fgiij (90.0). 

Syrupi aurantii q. s. ad. fgvj (180.0).— M. 

S.— Dessertspoonful (8.0) to a tablespoonful (16.0) one hour before sweat is ex- 
pected- 

In the writer's experience, camphoric acid is possessed of little 
power in cases of bromidrosis. 

CANNABIS. 

Indian Hemp (Cannabis, U. S., and Cannabis Indica, B. P.) is the 
flowering tops of the female plant of Cannabis sativa. It is to be 
distinctly separated from the so-called American, American-Indian, 
or Canada hemp, or Apocynum Cannabinum, which in full doses is 
an intense irritant and drastic. The active principle is a resinous 
substance called cannabinol. American- grown Cannabis sativa has, 



CANNABIS. 175 

however, been proved by Houghton to be equally active with 
imported Cannabis sativa. 

The selection of this drug is^ attended with peculiar difficulties 
because of the fact that only the non-fertilized female flower-spikes 
are possessed of therapeutic activity, the male spikes and female 
flower-tops, which are bearing seed, being inert. The three varieties 
resemble one another so closely that when crushed and intimately 
mixed in a bale it is practically impossible for even a drug expert to 
distinguish the active from the inert parts of the plant. 

Physiological Action. — Given in full dose to man, this drug causes 
exhilaration and incessant laughter arising from the slightest cause, 
the person seeming convulsed with merriment ; in other cases the sen- 
sations are disagreeable, and even death may seem imminent to the 
deranged mind. Sometimes the sensation of very full breathing comes 
on, and the patient thinks he is about to burst from the inflation of 
his lungs. After this, deep sleep ensues, lasting for many hours, even 
as many as fourteen or fifteen, without intervals of wakefulness. One 
of the most constant and marked symptoms in poisoning in man is the 
sensation of prolongation of time, so that minutes seem like hours, and, 
in addition to this, a peculiar separation of the mental powers occurs, 
during which both hemispheres of the brain seem to think differently 
on the same subject, If the dose be very large, the respirations are 
slowed very considerably, but no death from the use of cannibis indica 
by man is on record, and enormous amounts have been given to the 
lower animals without causing a lethal eifect. 1 Applied to a mucous 
membrane, it acts as a severe irritant, and then as a local anaesthetic, 
but the primary effect is so powerful as to prevent its application to 
mucous membranes for the relief of pain. 

Therapeutics. — Cannabis indica is one of the best additions to cough 
mixtures that we possess, as it quiets that tickling in the throat, and 
yet does not constipate nor depress the system as does morphine. In 
advanced phthisis it is justifiable to keep the patient constantly in a 
state of quiet comfort by its use. For the relief of pain, particularly 
that depending on nerve-disturbance, hemp is very valuable. Before 
the introduction of antipyrine and its congeners, tincture of gelsemium 
and the tincture or extract of cannabis indica were our best remedies 
in the treatment of migraine. The gelsemium in such cases should be 
given in full dose, 20 drops (1.3) of the tincture, and be followed by 
10 to 20 drops (0.60—1.3) of the fluidextract of cannabis indica, it 
being known that the sample about to be used is active. After this 
dose of gelsemium the patient should be carefully watched, lest he 
suffer from an excessive influence of the drug, as such an amount may 
produce great depression in susceptible persons. In true migraine with 
hemianopsia this treatment is often most effectual in aborting the 

1 The author has injected as much as 5 drachms of a fluidextract, active in the dose 
of 10 minims to man, into the jugular vein of a small dog without producing death 
for many hours. 



176 DRUGS. 

attack. The prevention of further attacks is to be attained by the use 
of smaller amounts of the cannabis indica during the intervals, the gel- 
semium only being used at the onset of the symptoms. In paralysis 
agitans cannabis indica may be used to quiet the tremors, and in 
spasm of the bladder, due to cystitis or nervousness, it often gives 
great relief. In sexual impotence, not dependent upon organic disease, 
it is said to be of value combined with strychnine or nux vomica and 
ergot. It acts as a nervous sedative in exophthalmic goitre. 

In headaches at the menopause cannabis indica is useful, and if the 
headaches are associated with constipation and anaemia, iron and aloes 
should be given simultaneously. Where headaches are due to retinal 
asthenopia a very useful prescription, according to de Schweinitz, is 
as follows : 

B— Tincturae nucis vomicae f3ij (8.0). 

Tincturae cannabis f3ij (8.0).— M. 

S. — 15 drops (1.0), in water, twice or thrice a day. 

The following prescription has been found to be very efficient in 
the hands of the author in treating gastralgia and other forms of abdo- 
minal pain : 

1^— Tincturae capsici' f3j (4.0). 

Tincturae cannabis . . 6 fgss (16.0). 

Tincturae opii deodorati f§j (30.0). 

Tincturae chloroformi f5j (30.0). 

Tincturae lavandulae compositae . . q. s. ad f3iv (120 0).— M. 
S. — Teaspoonful (4.0) every hour until pain is relieved. 

In cases of uterine subinvolution, chronic inflammation, and irritation 
cannabis indica is of great value, and it has been found of service in 
metrorrhagia and nervous and spasmodic dysmenorrhea. Not only 
does it relieve pain, but it also seems to act favorably upon the mus- 
cular fibres of the uterus. 

In acute and chronic BrigMs disease cannabis indica often allays the 
painful sensations over the renal region, and has been recommended 
by some writers in the cases in which bloody urine is present. In 
gonorrhoea it is said to decrease the discharge and prevent chordee, and 
it has supplanted the use of copaiba and cubebs in some practitioner's 
hands. It should not be used in the early stages of gonorrhoea, but 
in the later or subacute stages. There is some foundation for the 
belief that in small doses it acts as a sexual stimidant. 

The advantages possessed by cannabis indica are that it does not 
constipate nor cause after-depression and nausea. On the contrary, 
there is often an increase rather than a decrease of the appetite under 
its influence. In the Anglo-Saxon race the cannabis indica habit is 
practically unknown, but in the East Indies when used to excess it 
sometimes causes maniacal insanity, from which the patient nearly 
always recovers after some days, weeks, or months. 

Administration. — The employment of this most valuable remedy is 



CANTHARIS. 177 

handicapped by its frequent lack of power — a fault which is largely 
dependent upon reasons already given. Only a preparation which 
has been physiologically tested should be used. The physician should 
always employ some preparation known by him to be active by per- 
sonal trial before condemning the drug as a failure in a given case. 
The dose of the solid extract (Extractum Cannabis, U. S. and B. P.) 
is from \ to \ grain (0.015-0.03), that of the fluidextract (Fluidex- 
tradum Cannabis, U. S.) from 4 to 20 minims (0.25-1.3), and that 
of the tincture {Tinctura Cannabis, U. S. and B. P.) from 15 minims 
to 1 drachm (1.0-4.0), 5 to 15 minims (0.3-1.0), B. P. 

CANTHARIS. 

Cantharis (U. S.), or "Spanish Fly," is really a beetle, known 
as Cantharis vesicatoria, and as such appears with iridescent cover- 
ings or wing-sheaths of a bluish or greenish hue. The insects come 
chiefly from Spain, Italy, and Sicily, and from the southern parts 
of Russia. Those from Russia are supposed to be the best. Accord- 
ing to Leidy, the vesicating substance is in the blood, the eggs, and 
the secretions of the generative apparatus. The blistering sub- 
stance contains cantharidin, an active principle, which has sup- 
planted cantharis in the new B. P. 

Physiological Action. — Locally applied to the skin, cantharides 
causes irritation and finally vesication. The blister produced may be 
quite large, and enough of the drug may be absorbed to cause fever 
and nervous excitement. The ingestion of a moderate dose of can- 
tharides produces a sensation of warmth in the stomach and slight stim- 
ulation of the genito-urinary system, particularly the kidneys and 
urinary tracts. Large amounts produce great pain in the lumbar 
region, a sensation of heat in the bladder and the urethra, priapism, 
agonizing vesical tenesmus, widespread acute nephritis, bloody urine, 
which is scanty at first, and finally suppressed, with great irritation 
of the external openings of the genito-urinary apparatus. The inflam- 
matory changes may cause sloughing of the penis or of the labia in 
the female. 

Violent gastro-enteritis is nearly always a pressing condition. A 
diagnostic sign of cantharidal poisoning, when the beetles have been 
swallowed, is the appearance of pieces of the iridescent wing-sheaths 
or coats in the vomit. Thirst is always a prominent symptom of 
poisoning by cantharides. 

Therapeutics. — Cantharides are employed internally and externally. 
When given by the mouth the tiucture is used as a uterine stimulant, 
to affect the uterine mucous membrane and relieve amenorrhcca in cases 
in which atony and depression are the cause of the depression. Some 
persons teach that the tincture of cantharides is a valuable remedy in 
small doses in the second stage of acute desquamative nephritis, but in 
the instances where the writer has seen it used it has aggravated the 
12 



178 DRUGS. 

condition, although it is supposed to decrease the excretion of the albu- 
min and blood. In the later stages, where the kidneys are relaxed 
and torpid or where albuminuria comes on on the slightest exertion, 
tincture of cantharides in the dose of J minim (0.025) three times a 
day is of service. 

In cases of chronic parenchymatous nephritis, particularly where 
alcoholism is the cause of the disease and the kidneys are inactive, can- 
tharidal tincture is very useful. In pyelitis and in chronic cystitis it 
is of service, and it has been recommended highly in drop, doses in 
irritability of the bladder in women and children. In these cases the 
bladder must not be inflamed, but irritable from depression. The use of 
cantharides is of value in incontinence of urine of a minor degree, as 
that occurring in elderly or nervous females when coughing, sneezing 
or laughing, and will often give relief after years of suffering. In chor- 
dee, in the dose of J- minim (0.025) twice or thrice daily, it is some- 
times of service. For impotence depending upon sexual excess Ringer 
asserts that the use of 5 to 8 minims (0.30—0.50) of the tincture of 
cantharides, with full doses of the tincture of the chloride of iron and 
nux vomica, will often relieve the patient and enable him to beget chil- 
dren. This dose of cantharides must be given with caution. The drug 
has no true aphrodisiac influence except when given in almost toxic dose. 
In gleet of a very chronic type and in prostatorrhwa it is of service. 
Dermatologists have used cautharides internally as a remedy in psori- 
asis, eczema, lichen, and prurigo, with asserted great success. The 
dose should not be large enough to irritate the stomach or kidneys. 

Externally, cantharides are used in the production of blisters for 
the purpose of causing the absorption of effusions or as a counter- 
irritant of some severity in cases of deep-seated inflammations. (See 
Counterirritation.) Care should be taken that a sufficient amount of 
the drug is not absorbed to cause strangury and renal irritation. In 
renal congestions and inflammations the use of cantharides as a coun- 
terirritaut is often contraindicated because of this danger. Huchard 
and others have reported cases in which, without the disease of the 
kidney, a cautharidal blister has produced violent acute nephritis, with 
resulting uraemia. In proportion of J minim (0.025) of the tincture 
of cantharides to 40 minims (2.6) of water it is said to be an efficient 
application for burns, but how it acts is not known. 

Administration. — The dose of the tincture (Tinctura Cantharidis, 
U. S. and B. P.) is from i to 5 minims (0.025-0.30), and it is the only 
preparation used internally. The cerate (Ceratum Cantharidis, U. S.) 
is used, spread upon muslin, to produce a blister, and the cerate of the 
extract, which is no longer official, is used for the same purposes and in 
the same manner. The cantharidal collodion (Collodium Cantharida- 
tum, U. S.; Collodium Vesicans, B. P.) is a method of applying the 
blister which is most cleanly, but there is more danger of absorption 
of the drug if it is used. Emplastrum Cantharidis, U. S., is also 
official. Liquor Epispasticus, B. P., is employed as a counter- 
irritant, 



CAPSICUM. 179 

"Warming plaster" (Emplastram Picis Cantharidatam) is a mild 
counterirritant plaster to be employed where a blister is thought to 
be too severe. The preparations of the B. P. other than those 
named are Emplastrum Cantharidini and Unguentum Cantharidini. 

The unofficial plasters of cantharides are the best preparations to 
use for the production of a blister. In order to obtain a perfect effect 
the skin should be washed thoroughly with soap and water and dried 
with a towel, which should be rough enough to produce reddening of 
the cuticle. After this the skin should be moistened with vinegar, 
and while wet the blister is to be applied. 

CAPSICUM. 

Capsicum, U. S., Capsici Fructus, B. P., or Cayenne Pepper, is the 
fruit of Capsicum fastigiatum a native of tropical Africa and of Central 
America. It occurs in long ovoid pods, which, when ripe, are scar- 
let red and possess a very hot, burning taste. The active principle is 
capsicine, which is a dark reddish liquid, and which is a volatile al- 
kaloid. 

Physiological Action. — Locally applied to the skin or mucous mem- 
branes capsicum causes redness, and finally, in the case of mucous 
membranes, vesication. The alkaloid will also produce these changes 
in the skin. When used internally for any length of time in excess 
capsicum will cause a chronic or subacute gastritis with pain and dis- 
comfort over the liver and stomach. If single large doses are used, 
renal irritation and inflammation ensue, with strangury and the pass- 
age of concentrated urine. Taken internally, capsicum is said to act 
as a circulatory stimulant. 

Therapeutics. — In cases of atony of the stomach due to general debility, 
errors in diet, and alcoholism of the chronic type capsicum is oue of 
the best remedies we have. When the patient is suffering from acute 
alcoholism the gastric mucous membrane is often too much irritated to 
permit of its use, but after the lapse of some days it may be found of 
benefit for the purpose of increasing the digestive power. As a remedy 
for subacute alcoholism it is useful, since by its stimulating effect 
and hot sensation it often satisfies, at least to some degree, the crav- 
ing for alcohol. Under these circumstances it should be used in the 
dose of 3 to 5 minims (0.20-0.30) of the tincture every four or five 
hours, or as the oleoresin in pill in the close of J to 1 grain (0.03-0.06). 
The following prescription has been found of great service in these 
cases : 

ty — Tincturae capsici foiss (6.0). 

Tincturae opii deodorati . f o i j (8.0). 

Spiritus chloroformi foj (30.0). 

Tincturae lavandulae compositse . q. s. ad f§iv (120.0). — M. 
S. — Dessertspoonful (8.0) every four or five hours. 

In the flatulent colic of old persons and young adults capsicum will 
be found not only to act as a carminative, but also to prevent the 



180 DRUGS. 

development of the gas. In low fevers it has been used as a diffusible 
stimulant, but it is of doubtful value. It is rather in the anorexia 
of convalescence that capsicum acts most favorably. In chronic ne- 
phritis it is of considerable service, and tends to check albuminuria, but 
it is only to be used in the chronic forms and stages of renal disease or 
in the treatment of functional torpidity of the kidney. The tincture 
is to be given under these circumstances in the dose of 10 minims 
(0.60) or less, but in some cases which are very chronic as much as 
20 minims (1.3) may be used. In sore throat and simple tonsillitis 
the tincture of capsicum and glycerin, half and half, form a very use- 
ful local application applied by means of a swab. The same prepara- 
tion may be used as a gargle for relaxed uvula and sore throat. 

Capsicum may be used as a gastro-intestinal stimulant to aid in the 
absorption of other drugs. Applied externally, capsicum acts as a 
counterirritant, producing redness of the skin, but not a blister, in the 
ordinary individual. It is one of the best moderate counterirritants 
which can be used, and it may be employed by repeatedly saturating 
blotting-paper in the tincture of capsicum, allowing the paper to dry 
between each dip. This paper should finally be placed when warm and 
wet over the part, and held closely to the skin by a compress. Cap- 
sicum plaster {Emplastrum Capsici, U. S.) is useful in lumbago and rheu- 
matism when placed over the affected muscles, and in headache when 
applied to the nape of the neck. The tincture is sometimes painted 
over chilblains which are unbroken. The following method, given by 
Ringer, is very efficacious in this annoying affection : 

" Make a strong tincture of capsicum-pods by steeping them for 
several days in a warm place in twice their weight of rectified spirit 
of wine. Dissolve gum arabic in water to about the consistence of 
treacle. Add to this an equal quantity of the tincture, stirring together 
with a small brush or a large camel's-hair pencil until they are well 
incorporated. The mixture will be cloudy and opaque. Take sheets 
of silk or tissue-paper; give them, with the brush, a coat of the mix- 
ture ; let them dry, and then give another coat. Let that dry, and if 
the surface is shining, there is enough of the peppered gum ; if not, give 
a third coat. This paper should be applied in the same way as court- 
plaster to chilblains that are not broken and burns that are not blis- 
tered, and it will speedily relieve the itching and pain. It acts like 
a charm and effects a rapid cure. The same is true of discolored 
bruises. It likewise allays rheumatic pains in the joints." 

The dose of capsicum is 1 to 10 grains (0.06-0.65) in powder, or 
food or in pill. The dose of the tincture of capsicum ( Tinctura Capsici, 
U. S. and B. P.) is 5 to 20 minims (0.30-1.3), and of the oleoresin 
(Oleoresina Capsici, U. S.), J to \ minim (0.015-0.025). The dose 
of the fluidextract (Fluidextractum Capsici) is 1 to 3 minims (0.05- 
0.20). The plaster (Emplastrum Capsici, U. S.) is useful for external 
applications. An ointment (Unguentum Capsici) is official in the 
B. P. 



CARBON (CHARCOAL). 181 

CARBON (CHARCOAL). 

Carlo Ligni, IT. S. and B. P., or Charcoal, is prepared by the 
exposure of soft wood to a red heat, air being prevented from coming 
in contact with the wood during the process. Charcoal when used 
for medicinal purposes should be a black, brittle, somewhat shiny, 
porous substance, devoid of taste and odor, and completely insoluble 
in water. 

Therapeutics. — Charcoal is used externally as an application to old 
sores and sloughs to act as a deodorant and antiseptic. These things it 
accomplishes by the absorption of any liquids which may be present, 
thereby depriving germs of a nidus, and by its distinct oxidizing 
power. It may be applied in the form of a dry powder or in a 
poultice, which is, however, so uncleanly that other antiseptic dress- 
ings are perferable. 

The poultice (Cataplasma Carbon is), if used, should be made in 
the following manner : Take of powdered woodcharcoal J ounce 
(16.0), bread-crumbs 2 ounces (60.0), linseed meal 1J ounces (45.0), 
and add boiling water 10 fluidounces (300.0). Macerate the bread- 
crumbs and meal for ten minutes over a fire, and then stir in the 
charcoal to the extent of half the amount just named. Spread out 
the poultice and sprinkle the remaining half of the charcoal over its 
surface, and apply while hot to the part affected. 

Internally, charcoal is used in powder in many conditions, and acts 
very well indeed in cases of so-called " sour stomach " from which 
eructations of gas or sour liquids take place. 

The following prescription will also be found useful in the atonic 
or subacute gastric catarrh of persons who are careless in eating and 
who have much belching : 

]$ — Oleoresinae capsici gtt. x vel xx (0.60-1.3). 

Pancreatini .............. gr. xx (1.3). 

Pulveris zingiberis .......... gr. xl (2.6). 

Pulveris carbonis ligni gr. xl (2.6). — M„ 

Pone in capsulas No. xx. 

S.— One or two t. i. d. with meals. 

As ordinary charcoal is not always obtainable, it may be substi- 
tuted by pieces of very thin toast burnt through and through until they 
resemble charcoal. If the attack is very severe and vomiting eventu- 
ally ensues, the ejecta will commonly be found to be odorless and not 
sour, and the stools will also be almost odorless, though black. In 
fermentative and acid diarrhwas in adults this method of treatment is 
often of value, the prescription given above being a valuable means 
of cure. "When charcoal is used in any condition associated with 
irritation of the mucous membranes of the gastro-intestinal tract, it 
should always be very finely pulverized, and if the stomach or bowels 
are inflamed the capsicum must be excluded from the prescription. 

As a filter for impure water, charcoal, in mass or in powder, is one 
of the most satisfactory substances we have. 



182 DRUGS. 



CARDAMOM. 



Cardamom (Cardamomi Semen, U. S.) is the seed of Elettaria 
repens, and is a bitter tonic possessing some aromatic properties. It 
is useful in cases of atony of the stomach and small intestine, particularly 
if combined with a mineral acid or some other bitter tonic, such as 
gentian. Cardamom is official in the B. P. as Cardamomi Semina. 

If the intestine is atonic and secretion is deficient, the following 
prescription will be found of value : 

1^— Acidi nitrici diluti f3j (4.0). 

Tincturae cardamomi compositae . . . q. s. ad. fgvj (180.0). — M 
S. — Dessertspoonful (8.0) after each meal. 1 

Administration. — The official preparations of cardamoms are the 
tincture of cardamoms {Tinctura Cardamomi, U. S.)., dose 1 to 2 
drachms (4.0-8.0); and the compouud tincture {Tinctura Cardamomi 
Composita, U. S. and B. P.), which is to be given in the same dose as 
the tincture. This tincture also contains cochineal, cinnamon, cara- 
way, and glycerin. Cardamom is also a constituent of the official 
aromatic powder (Pulvis Aromaticus, U. S.). 

CASCARA SAGRADA. 

Cascara Sagrada (U. S. and B. P.) is the bark of Rhamnus 
Purshiana, a plant growing in California. It is sometimes called 
California buckthorn, to distinguish it from ordinary buckthorn 
or Rhamnus Frangula, which it closely resembles in many ways, 
and which may be used as a substitute for cascara sagrada in some 
cases. 

Therapeutics. — Cascara sagrada ought never to be used as a purge, 
but only as a laxative. It is by far the best remedy we have when 
employed simply to empty the bowel of fsecal matter in cases of 
constipation, since it not only performs this function without intes- 
tinal disturbance, but also simultaneously acts as a tonic to the 
intestine, and so prevents the constipation which usually follows the 
use of all other drugs of its class. 

In the United States cascara sagrada is most commonly employed 
in the form of the fluidextract {Fluidextr actum Cascara? Sagrada, 
U. S., or Extraction Cascara? Sagrada? Liqnidum, B. P.), in the 
dose of from 10 to 20 minims (0.60-1.3), | to 1 fluidrachm 
(2.0-4.0), B. P., at night or morning and night. If 20 minims 
(1.3) fail to act 30 minims (2.0) may be used; but if larger doses 
are required, other drugs should be employed as adjuvants, as 
fluidrachm doses of the fluidextract of cascara may produce irrita- 

1 While the rule that an acid is incompatible with a tincture is not recognized in 
this mixture, the quantities of acid and alcohol are so disproportionate that ether in 
any amount is not developed. 



CASTOR OIL. 183 

tion of the bowel, and enteritis or intestinal catarrh. The objec- 
tion to cascara sagrada is its bitter taste, which may be partially 
disguised by the additional use of Syrupus Aurantii, in the propor- 
tion of 1 part of the cascara extract to 2 parts of the syrup of orange- 
peel, or the aromatic fluidextract of cascara sagrada (Fluidextractum 
Cascarce Sagrada 3 Aromaticum, U. S.), may be given in the dose of 
from 10 to 30 minims (0.6-1.3). The B. P. has a preparation, 
Syrupus Cascara Aromaticus, which is given in the dose of \ to 2 
drachms (2.0-8.0). 

Some of the preparations of this drug are now made in an almost 
tasteless form, such as "Cascara Cordial," an aromatic preparation 
useful for children who are constipated, or the non-bitter fluid- 
extract made by a prominent firm in the United States and called 
"Cascara Evacuant," and used in the dose of 20 minims (1.3). The 
solid extract (Extraction Cascarce Sagrada 3 , U. S.; Extraction Cas- 
cara 3 Sagradce Siccum, B. P.) is given in the dose of 2 to 8 grains 
(0.12-0.5). 

CASSIA FISTULA. 

Cassia Fistula is the fruit of Cassia Fistula, or Purging Cassia, 
as it is sometimes called, and occurs in long, dark-brown pods con- 
taining a dark pulp in each segment. This pulp is the useful part 
of the drug, and is official in the B. P. as Cassia 3 Pulpa. Cassia fistula 
ought never to be used alone, as it is apt to cause pain and griping, 
but is officially present in the Confection of Senna (Confectio Senna 3 , 
B. P.), and may be given in the dose of J to 1 drachm (2.0-4.0) as a 
laxative, or as much as § ounce (16.0) may be used if a purgative 
effect is desired. 



CASTOR OIL, 

Castor Oil (Oleum Ricini, U. S. and B. P.) is a fixed oil derived 
by expression from the beans of Ricinus Communis, a plant of the 
United States and elsewhere, but originally derived from India. It 
contains an acrid substance, ricinoleic acid. 

Physiological Action. — The manner in which castor oil purges is 
somewhat in doubt, but its activity probably depends upon the pres- 
ence of ricinoleic acid set free by the alkaline juices of the intestine 
and the fact that it is an oil. 

As is well known, oils — such as olive oil, for example — if given in 
considerable quantity, tend to move the bowels, and the ricinoleic acid, 
which is somewhat acrid, stimulates the small and large gut, and so 
develops peristaltic movement. That this acid possesses purgative 
properties of itself seems proved by the fact that the oil will purge 
when it is rubbed on the skin, and that nursing mothers on taking 
the oil eliminate the acid in the milk to such an extent that the suck- 
ling is purged. According to the studies of Rutherford and Vignal, 



184 DRUGS. 

the oil has no effect over biliary secretions other than that violent 
purgation indirectly increases the flow, and the researches of Hess 
have shown that the oil acts more rapidly in the small than in the 
large gut, and produces peristalsis only by coming in contact with the 
mucous membrane. 

Therapeutics. — Castor oil is the blandest and most unirritating 
purge we have, with the exception of the sulphate of magnesium, 
which is depletant and much more rapid in its effects. While Epsom 
salt will act in one- half to one hour if the stomach is empty, castor 
oil will generally act in four hours, or perhaps five. 

Castor oil is used whenever irritant materials, such as bad food, 
putrid flesh or decaying or green vegetables, have been eaten, even if 
the inflammation set up after them is very active. If hard bodies, such 
as broken cherry-stones, have been swallowed, castor oil is a far better 
purge than sulphate of magnesium, as it is more gentle and lubricates 
the gut, thereby preventing scraping and irritation. Where mucous 
has accumulated in the bowel in children, and must be gotten rid of 
before other treatment is resorted to, castor oil should be used. 

Previous to parturition it has been largely used to relieve the 
bowels of faecal matter, and is said by some practitioners to make the 
labor easier than if any other purge is used. This is doubtful. It 
is also employed in" the constipation following acute diseases and in 
that occurring in infants and children. 

The disadvantages of castor oil lie in its taste, the fact that it is oily, 
that it tends to produce hemorrhoids if used constantly, and finally 
that its frequent use, or even a single dose, is generally followed by 
more obstinate constipation than existed before, so that the dose must 
be rapidly increased in size to be effective. This is one of the reasons 
why it is useful in irritative diarrhoeas, for, having swept out the 
mucous and offending matter, it checks the movement of the bowels 
afterward. The purgative effect of castor oil is very much increased 
if a little bicarbonate of sodium is given with it. 

A very effective purge in very obstinate constipation consists of 1 
ounce (30.0) of castor oil with 1 ounce (30.0) of aromatic syrup of 
rhubarb. 

Some cases of severe neuralgic headache may be cured by the use 
of small daily doses of castor oil. How it acts is not known, unless 
it unloads the bowels and so prevents toxaemia, which in turn has 
caused nervous irritation. 

Castor oil, to which has been added a few drops of balsam of Peru 
or oil of eucalyptus, when placed freely on gauze is an excellent 
dressing for ulcers, wounds, and burns. 

Administration. — Castor oil is very much less disagreeable to the 
taste if pure than if poorly prepared. It is also true that too great 
purification renders it less active. 

The methods directed for taking castor oil are as various as the 
tastes of individuals. Its odor may be masked by a drop or two of 



CAUSTIC SODA. 185 

the oil of bitter almonds, but emulsions of the oil are not of any ser- 
vice, save to interfere with its efficiency. Some take the oil in the 
foam of beer or porter, others in syrup of sarsaparilla and soda-water, 
and still others in milk or cream. A good way to take it is to eat one 
or two strong so-called cream peppermint drops, or even the crystal- 
line peppermint drops, swallow the oil from a spoon which is to be 
placed well back in the mouth, and immediatly eat several other 
peppermints. This plan is improved by using the oil in milk or water, 
so that the liquid carries the oil down into the oesophagus without its 
touching the mucous membranes. It may also be taken in highly 
seasoned beef-tea. Ringer recommends the following : J ounce (16.0) 
of oil, fresh syrup of acacia 3 drachms (12.0), and distilled water 5 
drachms (20.0), flavored with a little oil of lemon or peppermint. 
AVood advises that it be mixed with glycerin, equal parts, to which is 
added a drop or two of oil of gaultheria or oil of cinnamon. Hitter 
advises the following formula : 

1^ — Saccharini gr. ii (0.12). 

Olei menthae piperitae gtt v (0.30). 

Alcoholis q. s. fiat solutio. 
et adde : 

Olei ricini fgviii (240.0). 

Sig.— One or two tablespoonfuls as needed. 

By far the best way of administering it is in soft capsules contain- 
ing from \ to 1 drachm (1.0-4.0). Most persons can swallow as 
much as a teaspoonful in capsule, and several capsules containing this 
quantity, or a smaller amount, may be given at once to complete the 
necessary dose. The capsules should be dipped in water in order to 
render them slippery and so more easily swallowed. 

The dose of castor oil for an infant is 1 to 2 fluidrachms (4.0—8.0), 
and for an adult \ to 1 fluidounce (16.0—30.0). Often, however, small 
doses will act when it is desired to sweep out of the bowel foreign 
matter that is causing diaiThopa. 

Owing to the fact that the oil will very frequently produce griping, 
a few drops of laudanum should be added to it, or tincture of bella- 
donna may be used. If these cannot be employed, a drop of the oil 
of cinnamon is equally useful for this purpose. 

Under the name of Mistura Olei Ricini the B. P. recognizes a mix- 
ture of castor oil made into an emulsion and given in the dose of 1 
to 2 fluidounces (30.0^60.0). 

CATECHU. 

(See Gambir.) 

CAUSTIC POTASH. 

(See Potassium Hydroxide.) 

CAUSTIC SODA= 

(See Sodium Hydroxide.) 



186 DRUGS. 



CERIUM OXALATE. 



Cerium Oxalate (Cerii Oxalas, U. S.) is a white granular powder, 
permanent when exposed to the air, odorless and tasteless, and 
insoluble in water and alcohol, but freely so in hydrochloric acid. 

Therapeutics. — Cerium oxalate is often used instead of, or combined 
with, bismuth in the treatment of vomiting, and in some cases of gastric 
acidity. The dose is from 2 to 5 grains (0.12-0.3), given in pill-form 
every four or five hours. 

CHENOPODIUM. 

Chenopodium is the fruit of Chenopodium ambrosioides, or Ameri- 
can wormseed. The seeds contain a volatile oil and have a distinct 
and rather disagreeable aromatic odor. The oil (Oleum Chenopodii, 
U. S.) is a most efficient remedy for Ascaris lumbricoides, or round- 
worm. Recent tests show that this oil is often even better than thymol 
in uncinariasis, and its efficiency, unlike thymol and aspidium, seems 
to be increased by castor oil. The dose for an adult is 15 to 20 minims 
(1.0-1.3). The dose is 10 minims (0.6) to a child of five years either 
on sugar or in an emulsion made with acacia. If the patient is old 
enough, capsules may be used. The drug if too freely given is distinctly 
poisonous. The general dietetic measures adopted for the removal of 
worms should be insisted upon before the drug is given and a saline 
purge administered one hour after the drug is swallowed. (See 
article on Worms.) 

CHLORAL HYDRATE. 

Although the name Chloral is applied to the substance used in 
medicine, chloral itself is never so employed, hydrated chloral (Chlor- 
alum Hydratum, U. S.; Chloral Hydras, B. P.) being the real prep- 
aration. Hydrated chloral is a white, crystalline body, but is often 
sold in irregular broken masses, which are generally impure. It 
should be kept in tight bottles in a cool, dark place. It is freely soluble 
in water, alcohol, or ether; also in chloroform, benzene, petroleum 
benzin, carbon disulphide, fixed and volatile oils. It liquefies when 
triturated with about an equal quantity of camphor, menthol, thymol, 
phenol, or antipyrine. 

Physiological Action. — When chloral is applied to a mucous mem- 
brane, it causes distinct reddening and burning pain, and finally acute 
inflammation. It is, therefore, a local irritant. Chloral acts in the 
body as chloral, and is not broken up into formic acid and chloroform, 
as was taught at one time. 

Nervous System. — In medicinal and toxic dose chloral produces 
sleep by quieting the intellectual centres in the brain, at the same 
time depressing the motor tract of the spinal cord and the motor 
nerves. It also depresses the motor area of the cortex. In medicinal 



CHLORAL HYDRATE. 



187 



amounts it does not decrease sensation, but in toxic doses it does. 
Very often hyperesthesia of the skin results from small doses. Reflex 
action is decreased by its sedative influence on the motor portions of 
the spinal cord. 



Fig. 20. 



Fig. 21. 





Fig. 23. 



Fig. 22. 






Fig. 20. — A, chloral causes sleep by quieting intellectual centres in brain. 

Fig. 21. — B, depresses motor centrifugal tracts of cord; C, depresses motor nerves; D, does 
not depress the muscles. 

Fig. 22. — E, depresses heart-muscle. 

Fig. 23. — F, depresses the respiratory centre in the medulla. 

Circulation. — A dose of 10 to 20 grains (0.60-1.30) in the healthy 
adult rarely causes any circulatory change, but larger amounts pro- 
duce a fall of arterial pressure due to depression of the vasomotor 
centre, and a slow, feeble, or sometimes a rapid-running pulse, due to a 
direct depression of the heart-muscle, for chloral in overdose is a car- 
diac paralyzant. 

After death from chloral the blood may be found dark and grumous 
looking, with the corpuscles broken down, but these changes occur 
only after very large doses. 

Respiration. — In moderate amounts no respiratory effect is felt, 
but in toxic doses the breathing becomes slower and slower and more 



188 DRUGS. 

and more shallow, until it stops in death. When death is caused by 
chloral it is primarily due to centric respiratory failure, but there is an 
almost simultaneous arrest of the heart. 

Temperature. — Chloral tends to lower bodily heat, and in large 
doses produces a marked fall of temperature, which does much 
toward causing death. Brunton has found that animals will survive 
very large doses of the drug if external heat is supplied to them. The 
fall of temperature is, at least in part, due to failure of the circulation 
and to vascular dilatation. 

Kidneys, Tissue-waste and Elimination. — Chloral is elimi- 
nated by the kidneys in combination with glyco-uronic acid in the 
form of uro-chloric acid, and, if given in excess, as chloral. Poison- 
ous doses irritate these organs, and may produce bloody urine, owing 
to the nephritis which is set up as the drug passes through the renal 
structures. After chloral is ingested, the urine of a patient will often 
react to Fehling's and Trommer's tests for sugar. 

Poisoning. — When a poisonous dose of chloral is taken, the individ- 
ual soon falls asleep and then sinks into a deep coma. The respir- 
ations become at first slow and labored, then shallow and feeble. 
The pulse, at first perhaps a little slowed, soon becomes thready and 
shuttle-like, and is finally lost at the wrist. The face is white and livid, 
the forehead and the hands covered with a cold sweat, and the pupils, 
which are at first contracted, soon become widely dilated. Absolute 
muscular relaxation is present, and it is impossible to arouse the patient. 

Very large doses of chloral have been swallowed and retained without 
causing death. Acher has recorded a case in which 330 grains (22.0) 
of chloral and the same amount of bromide of potassium were taken 
at one dose with the recovery of the patient, and Daley has recorded 
an instance in which recovery followed a dose of 595 grains (40.0). 

Treatment of Poisoning. — The physician should apply external 
heat and use emetics in the early stages, or, if the case is seen too late 
for emetics to act because of systemic depression, he should use the 
stomach pump. This latter means of removing the drug from the 
stomach is safer and more reliable, because the production of vomit- 
ing may result in efforts which will strain the heart. Strychnine should 
be given in full dose, -£$ to j-q grain (0.003-0.006), to stimulate respir- 
ation and the vasomotor system, and atropine may be used for the 
same purpose. The heart is to be supported by half -grain (0.03) 
doses of "digitalone" given hypodermically until some effect is noted, 
but, as digitalis is rather slow in its action, it should be preceded by 
ether and ammonia or brandy or whisky. The patient must not 
raise the head to vomit, and the head should be placed on a lower 
level than the heels to aid in maintaining the circulation of blood in 
the vital centres at the base of the brain. 

In Chronic Poisoning by chloral or in cases in which the 
patient has come to use the drug as a habit the patient suffers from 



CHLORAL HYDRATE. 



189 



weakness, mental and physical, with sudden flushings due to vasomotor 
disorder, from palpitation of the heart, and finally from petechial 
eruptions, bed-sores, ulcerations, and sloughs. 



Fig. 24. 




Shows the effect of digitalis in raising blood-pressure and pulse-force in chloral poisoning (after 
Schmiedeberg) : In I the pressure is very low because of the effect of a large dose of chloral; the 
blood-pressure is 40; in II, after the injection of digitalis, it is 60; and in III it is 125, and the 
individual pulse-beat is far stronger than before. 

Therapeutics. — Chloral is one of the purest hypnotics that we have, 
and may therefore be used where simple nervous insomnia is present, 
but not when sleeplessness is due to pain. When pain is present it is 
to be employed in the combination of 10 grains (0.60) of chloral with 
I grain (0.01) of morphine, as a much more powerful hypnotic effect 
is produced by the combined action of the two drugs than by the use 
of either one of them alone. 

The following prescription may be used: 

R— Chlorali hydrati 3 ij vel iv (8.0-16.0). 

Morphinae sulphatis gr ij (0.12), 

Syrupi lactucarii f,^ij(60.0). 

Aquae destillatse . . . q. s. ad f ^ iij (90.0). — M-. 
S. — Dessertspoonful (8.0), in water, at 10, and at 11 p.m. if necessary. 

Another formula is found on the next page. 

In tetanus and strychnine-poisoning chloral is one of the best remedies 
we have, as it depresses the motor tract of the spinal cord. In such a 
case it should be given in 20-grain (1.3) doses combined with 60 grains 
(4.0) of bromide of potassium. If the convulsion prevents deglutition 
or is brought on by swallowing, these remedies should be used by the 
rectum dissolved in starch- water; and if the spasm expels them from 
the rectum, the patient should be chloroformed long enough to allow 



190 DRUGS. 

the injection to be given and absorbed. The same remedies in small 
doses are to be used in infantile convulsions and in infantile colic 
in the dose by the mouth of \ to 1 grain (0.03-0.06) of chloral to 
2 grains (0.12) of 'bromide of potassium or sodium in a teaspoonful of 
peppermint- water and syrup. In chorea, paralysis agitans, and delir- 
ium tremens chloral is of great service, but must be given cautiously 
in the last-named condition, for fear it may depress the heart, which 
is already diseased by alcoholic excess. Cases are on record in which 
chloral has caused sudden death from cardiac failure in alcoholics 
with fatty heart — an accident the liability to which is increased by 
the fact that owing to the addiction of the patient to a narcotic drug 
it requires large doses of the chloral to produce sleep. In urcemic 
convulsions chloral has been highly extolled, but if any acute renal 
trouble is present, it must not be used lest it irritate the kidneys. In 
puerperal convulsions not dependent upon nephritis 20 to 30 grains 
(1.3-2.0) of the drug may be given, and repeated in one or two hours. 

Hiccoughs, nocturnal epilepsy, and whooping-cough are all indica- 
tions for its use, but in asthma it rarely does good, and if pushed is 
dangerous to the heart. 

Probably because of its counter-irritant properties chloral is some- 
times used locally over neuralgic nerves as follows : 

I$— Chlorali hydrati gr. c (6.5). 

Camphorae 5vj (24.0). 

Olei gaultheriae . . . f 5j (4.0). 

Alcoholis q. s. ad f 5j (30.0). 

Untoward Effects. — Chloral sometimes causes nausea, purging, and 
vomiting by reason of its irritant action. In susceptible persons doses 
of 10 to 15 grains (0.60-1.0) have produced marked redness and 
swelling of the conjunctiva. Sometimes the last-named symptoms are 
only produced when an alcoholic beverage is taken simultaneously. 
In still other cases an erythematous, papular, urticarial, vesicular, or 
petechial eruption may ensue, the latter forms being seen as a rule in 
cases of chronic chloralism to which the drug is given. 

Administration. — Chloral is best given in syrup of acacia, simple 
syrup, or water. It should always be well diluted. The syrup of 
chloral (Syrupus Chloral, B. P.) is given in the dose of \ to 1 fluid- 
drachm (2.0-4.0). The following prescription is useful in insomnia. 

3 — Chlorali hydrati 5J vel ij (4.0-8.0). 

Potassii bromidi 5ij (8.0). 

Syrupi pruni virginianae f S J (30.0). 

Aquae destillatae . . . . . q. s. ad f S ii j (90.0). — M. 
S. — Dessertspoonful (8.0) in water at night. 

Sometimes chloral can be well given in junket by adding it to a 
liquid rennet, and then adding the rennet to the milk. (See Junket, 
Part III.) 



CHLORAL FORMAMIDE. 191 

It is well to remember that if soluble salts like the bromides of 
sodium or potassium are placed in a prescription which also contains 
alcohol, chloral alcoholate may be found which is very irritating to 
the stomach. Alcohol should therefore be avoided, if possible, in such 
prescriptions. 

The question as to the safe dose of chloral is one largely governed 
by the susceptibility of the patient, but alarming symptoms have 
followed a dose of 30 grains, and death after from 30 to 45 grains. 
Thirty grains in twenty-four hours are certainly ample in most cases. 

CHLORAL FORMAMIDE (CHLORAL AMINE) . 

Chloral formamide (Chloral formamidum, B. P.) is a compound 
formed by the addition of formamide to anhydrous chloral, and is a 
colorless crystalline substance without odor and of a somewhat bitter 
taste. It is soluble in 19 parts of water and 1.6 parts of alcohol. 
Chloral formamide keeps well in watery solution without decomposi- 
tion. Its physiological action is closely allied to that of chloral, 
except that it is not quite so depressing to the circulation. Upon the 
nervous system it acts chiefly upon the brain and spinal cord, and 
produces sleep — a result to be expected, since both chloral and for- 
mamide are hypnotics. It is said not to irritate the stomach and 
kidneys, but it probably is only less irritant than chloral. 

Therapeutics. — Chloral formamide may be employed in medicine 
whenever chloral may be used. It is decidedly a nervous sedative, and 
in the wakefulness of nervous insomnia is very useful. Sleep generally 
ensues about thirty or forty-five minutes after it is taken. According 
to most of the reports published so far, the drug relieves pain as well 
as produces sleep, and is therefore distinct in its action from chloral. 
In neuralgia it is very useful, and it has been found of value in the 
pains of tabes dorsalis. The dose is 10 to 30 grains (0.60-2.0), which 
may be repeated in three or four hours, although the sleep generally 
lasts five to eight hours. The following formula may be used for its 
administration : 

B — Chloralformamidi gr. xl (2.6). 

Acidi hydrochlorici diluti ..... tr^v (0.3). 

Syrupi f oij (8.0). 

Aquae destillatse f oij (60.0).— M. 

S. — Take in two doses in a little water. 

The late Professor Charteris claimed very extraordinary results in 
the treatment of sea-sickness by the use of equal parts of chloralform- 
amide and bromide of potassium. He gave it in the dose of 30 grains 
(2.0) with an equal amount of the bromide. It is necessary for the 
patient to take a cholagogue for two days before starting on the voyage, 
and as soon as he boards the ship to take the dose named on an empty 
stomach, and at once go to bed and sleep. If this is done, Charteris 



192 DRUGS. 

claimed that the patient will awake feeling bright and well, and remain 
so for the rest of the voyage. This combination under the name of 
"chlorobrom" has been also largely used as a hypnotic in the treat- 
ment of the insomnia due to melancholia and acute mania. 

CHLORALOSE. 

Chloralose is a compound made from anhydrous chloral and glu- 
cose, is soluble in hot water and alcohol, and was introduced into 
medicine as a safe hypnotic and substitute for chloral. Unfortunately 
its taste is acrid, and to some persons nauseous, particularly if it is 
taken in water. 

Physiological Action. — The physiological action of chloralose is 
practically identical with that of chloral, but much more mild if the 
researches of Mosso are correct. Its dominant effect is on the brain, 
and full doses depress the spinal cord and heart. Poisonous doses 
may produce hsemoglobinuria. 

Therapeutics. — The indications for the drug are Junctional insom- 
nia, and the beginning dose is 2 to 7 grains (0.12-0.5), but the smaller 
dose should always be tried first, particularly in women. Sleep follows 
its ingestion in about half an hour. 

The best way to administer the drug is to give it in capsule or 
cachet, and to follow it with a glass of water or milk. 

Untoward Effects.— Sometimes chloralose produces diplopia, muscu- 
lar tremors, or constant passing of the hands over the head and face. 
If a habit is induced by its constant use, it is a noteworthy fact that 
its power to produce sleep is decreased, while the untoward effects are 
more likely to be marked. In nervous and tuberculous patients it 
sometimes causes tetanic or cataleptic symptoms with disturbed intel- 
lection. 

CHLORETONE. 

Under the name chloretone a substance, which is trichlor-tertiar\> 
butyl-alcohol, or acetone chloroform, is often used as a hypnotic and 
nervous sedative closely allied in its uses to chloral, yet differing in 
the important particulars that it does not depress the heart or respira- 
tion unless given in excessive quantities, and does not irritate the 
stomach, but acts as a sedative to this organ. For this reason it can 
be used with advantage in vomiting due to irritation. Given in the 
dose of 5 to 10 grains (0.30-0.65) before etherization, it will often 
prevent after-vomiting, and if vomiting has already begun, is a valu- 
able agent for its relief. When used to prevent ether vomiting, it 
should be given in powder one hour before the ether is used. It is a 
valuable remedy to prevent and relieve sea-sickness, in doses of 3 to 
5 grains (0.2-0.3) three times a day. Chloretone is an efficient pallia- 
tive in tetanus, given by the rectum in the dose of 60 grains (4.0) dis- 
solved in warm olive oil^ and repeated as often as is needed to 
control spasm. 



CHLORODYNE 193 

The author has also found it of value in relieving the pain of gastric 
ulcer and of gastralgia. As it is both anaesthetic and antiseptic, it can 
be employed as an application to burns, scalds, and lacerations in 10 
per cent, ointment, and local anaesthesia may be produced by the 
subcutaneous injection of it in a 1 per cent, solution of alcohol 15 per 
cent, and water 84 per cent. It may be dissolved in oil of cloves and 
applied on a cotton pledget with advantage in cases of toothache. It 
may also be used to benumb a painful dental nerve by mixing equal 
parts of ether and chloretone and applying this in the cavity. Pow- 
dered chloretone mixed with equal parts of powdered boric acid and 
dusted over painful ulcers, burns, and lacerations or wounds acts as an 
efficient antiseptic dressing, but it may increase the burning at first. 
Chloretone and antipyrine may be given in capsule in the dose of 3 to 
6 grains (0.20-0.4) each and used in restlessness and neuralgia pain. 
The mixture of these substances results in liquefaction, but this does 
not interfere with their therapeutic efficacy. 

Chloretone is efficient in doses of from 5 to 20 grains (0.30-1.3), 
and is best given in 5-grain capsules or in pills of about 3 grains (0.20) 
each. Large doses often cause headache as the effects wear off. 

CHLORINATED LIME. 

(See Calx Chlorinata.) 

CHLORODYNE. 

Chlorodyne is a preparation used largely for the treatment of 
serous diarrhea or cramps in the abdomen. Its constitution varies 
considerably, but the formula most commonly employed is as follows: 



1$ — Morphinse hydrochloridi 



Aquae destillatae 



gr. viij (0.5). 
f 5ss (2.0). 



Heat together, and as soon as the morphine is dissolved and the liquid cooled, add 

Acidi hydrochlorici diluti .... f 5ss (2.0). 

Chloroformi . . . . . . . . f 3iss (6.0). 

Tincturse cannabis . f 5j (4.0). 

Acidi hydrocyanici diluti .... TTtxij (0.8). 

Alcoholis f §ss (16.0). 

Olei menthse piperita? ..... Hlxij (0.8). 

Oleoresinse capsici tnj (0.05). — M. 

S. — 5 to 15 minims (0.30-1.0) for an adult, in water, every two hours for three 
doses. More than this quantity is dangerous. 

Under the name of Mistura Chloroformi et Cannabis Indices Com- 
posita the N. F. contains a recipe, each fluidrachm (4 mils.) of which 
represents about 7 minims (0.45 mil.) of chloroform, 10 minims (0.6) of 
tincture of cannabis indica, 2 minims (0.12) of tincture of capsicum, 
and \ grain (0.009) of morphine sulphate. 

A formula closely allied to this is used in tablet form. 

13 



194 DRUGS. 

CHLOROFORM. 1 

Chloroform (Chloroformum, U. S. and B. P.) was discovered by 
Guthrie (1831), of Sackett's Harbor, New York, and was first used 
medicinally (1847) by Simpson, of Edinburgh. It is a clear liquid 
consisting of 99 to 99.4 per cent., by weight, of absolute chloroform 
[CHC1 3 = 118.45] and 0.6 to 1 per cent, of alcohol. It should be kept 
in dark amber-colored, glass-stoppered bottles, in a cool and dark place. 
Chloroform has an exceedingly hot, burning, sweetish taste, has a rather 
agreeable odor, and is very volatile. Its chemical name is trichlor- 
me thane. It is soluble in 200 parts of water. 

There are two kinds of chloroform — the purified (Chloroformum, 
U. S.) and the commercial chloroform (Chloroformum Venale). 

If exposed to the light for any length of time, chloroform develops 
carbonyl chloride, hydrochloric acid, and chlorine, which render it 
unfit for use. If the acid is present, it will turn blue litmus red; and if 
chlorine is present, it will form a white precipitate with nitrate of silver. 
Such impure chloroform may be rectified by shaking it with slaked 
lime and filtering till the irritating products are gotten rid of. If impure 
because of improper methods of manufacture, an oily odor will be left 
on the hand after evaporation takes place. We find, therefore, that 
chloroform suitable for anaesthesia should be transparent and color- 
less, neutral to test-paper, non-irritating when inhaled, and should 
evaporate completely when placed on a watch-glass, leaving no residue 
or odor. It should have a specific gravity not below 1.476, should 
form no precipitate with AgNO s , should not become brown when heated 
with caustic potash, and only very faintly brown, if at all, when shaken 
with concentrated H 2 S0 4 . The method of manufacture of Pictet, by 
which the chloroform is purified by crystallization, probably gives 
the purest article. In America the chloroform marketed by Squibb, of 
Brooklyn, and Parke, Davis & Co. is almost universally employed. 

Chloroform vapor in the presence of a gas-flame undergoes certain 
changes which result in the development of noxious and irritating 
fumes, consisting principally of hydrochloric acid and chlorine, which 
produce laryngeal and bronchial irritation. The deleterious effects 
of these fumes can, however, be neutralized if a cloth or towel wet 
with aqua ammonia be hung up in the operating-room. 

Physiological Action. — Locally applied to the skin, chloroform may 
produce some tingling and burning even if evaporation be not inter- 
fered with. If confined under a watch-glass on the skin, it will cause 
a blister and act as a counterirritant. 

When inhaled, chloroform produces a sensation of warmth in the 
mouth and throat, a feeling of relaxation, and, finally, unconscious- 
ness. The respirations are at first full and deep, but soon become 
rapid and shallow. The pulse may be somewhat stronger and fuller 
for a short interval, probably because of mental excitement, but soon 

1 The student should read the article on Ether in conjunction with this article. 



CHLOROFORM 



195 



fails in strength and becomes more rapid. The irritation produced 
in the air-passages by its inhalation is slight, and no primary arrest 
of respiration ensues, as is generally seen after ether is first given. 
The pupils are at first slightly dilated, but are contracted during anses* 



Fig. 25. 



Fig. 26. 





Fig. 27. 




Fig. 25 — A, chloroform depresses the vasomotor centre; B, chloroform dilates the heart and 
depresses it; C, chloroform depresses the respiratory centre. 

Fig. 26. — A, chloroform produces anaesthesia by depressing the perceptive centres in the brain 
and later depresses the (£) intellectual centres, and finally depresses the (C) motor centre. 

Fig. 27.— D, depresses the sensory paths in the spinal cord; E, finally depresses motor tracts 
in the cord. 

thesia. If the pupils dilate during the use of chloroform after the con- 
traction just named, danger is imminent and death may suddenly occur. 
In some persons the first effects of chloroform are violent struggles, 
and there is danger in trying to overcome these struggles by pushing the 



196 



DRUGS 



drug very rapidly. Not only is this a well-recognized fact depending 
upon clinical observations, but Sherrington and Sowton have proved 
experimentally that the heart is peculiarly susceptible to the depressant 
effects of chloroform when it is simultaneously exposed to an abnormal 
quantity of C0 2 in the blood. Further than this Brodie has shown 
that the rate of absorption of chloroform is greater during the second 
minute of its inhalation than at any other time and that the volume 
expired is less during this period. Struggling is particularly apt to 
be met with in athletes and drunkards. Total muscular relaxation 
should never be produced by the drug. 



Fig. 28. 



B 



x 



Diagram to show effect of moderate doses of chloroform on the sensory paths of the spinal 
cord. From the area B, the pia mater is removed, so preventing the chloroform from reaching it. 
If the nerve-trunks (x or z) are irritated.no reflex takes place because the sensory parts are 
obtunded, but if nerve y is irritated, reflexes occur all through the cord because that sensory 
part is not obtunded, and the motor paths have not been touched. 

Nervous System. — Chloroform first affects the sensory part of the 
brain, then the sensory part of the spinal cord, then the motor tract of 
the cord, then the sensory paths of the medulla oblongata, and finally 
the motor portion of the medulla, thereby producing death from failure 
of the vasomotor centre and of the respiratory centre, unless, as rarely 
occurs, the heart has already succumbed to the drug. The effect on 
the sensory portion of the cord may be proved by the above experi- 
ment explained in diagram. 

On the sensory and motor nerves, when locally applied, it acts as 
an irritant and anaesthetic. Upon these nerve-trunks, when taken by 
inhalation, it has little or no effect. 

Meyer and Overton believe that chloroform acts as an anaesthetic 
by solution of the lipoid or fatty constituents of the brain cells. The 
solution is intracellular and the fat is not removed from the cell. 

Blood.— Upon the blood in the body chloroform has little or no 
effect when it is inhaled. Shaken with chloroform in a bowl, the blood 
becomes scarlet in hue. 

Buckmaster and Gardner have shown that anaesthesia develops in 
animals when the quantity of chloroform is from 14 to 27 milligrammes 
to 100 grammes of blood, and that death ensues when the proportion is 
40 milligrammes to 100 of blood. These investigators also found that 
the greater part of the absorbed chloroform is held by the corpuscles, 
the plasma holding very little. Harcourt believes that the quantity 
absorbed is about one-third of that inhaled. 



CHLOROFORM 197 

Circulation and Respiration. — The effects of chloroform upon 
these vital functions have been for many years a subject of hot dis- 
pute between surgeons and pharmacologists. On the one hand is 
the school originally led by Syme, of Edinburgh, which has asserted 
that death or danger from chloroform lies in failure of the respiration 
and that this was the function to be watched while chloroform was 
being used; on the other hand, the so-called London school asserted 
that death arises from cardiac failure and that the pulse is the thing to 
be watched during the use of chloroform. The number of clinical and 
laboratory researches which have been carried out to determine which 
of these opinions is correct has been very great, both in England and 
in America, but it has only been within the last twenty years that the 
most competent studies have been undertaken, of which the best known 
is the series made through the munificence of His Highness the Nizam 
of Hyderabad in India, and known as the "Reports of the Hyderabad 
Chloroform Commissions Nos. 1 and 2." The conclusions of the first 
commission having been criticised adversely because it asserted that 
the cause of death was respiratory failure, a second commission was 
formed, and, under a grant of $5000 from the Nizam, Sir Lauder 
Brunton, of London, was sent out to direct the second investigation. 
Although a teacher of the theory that death from chloroform is due to 
cardiac failure, this investigator returned to England converted to the 
idea that the cause of most of the fatal accidents under this drug 
is respiratory failure, and the conclusions of Commission No. 2 
were also criticised by numerous clinicians and pharmacologists in 
England and America. About this time H. C. Wood and the author 
published a paper in which they expressed their belief in the depress- 
ing effects produced by chloroform upon the heart; and Mac Williams, 
of Glasgow, proved by experiment that chloroform causes cardiac 
dilatation and enfeeblement. Shortly afterward the author of this 
book was requested by the government of His Highness the Nizam, 
through Colonel Edward Lawrie, the Residency Surgeon, to carry 
out a series of studies 1 designed if possible to reconcile the contra- 
dictory results reached by the Hyderabad Commissions and other 
investigators, and simultaneously Gaskell and Shore in Cambridge 
University, England, were asked to do likewise. The result has been 
to confirm in every way the results of all previous studies in one respect 
— namely, that the primary action of chloroform on the vital function 
of circulation is greatly to depress the vasomotor system, thereby 
causing an extraordinary fall of blood-pressure. Gaskell and Shore, 
to be sure, assert that ansesthesia can be produced by chloroform 
without causing this fall, but the author has never been able to do 
so (Fig. 29) . They also believe that the fall is chiefly a result of cardiac 
failure. From this view the author dissents, because their experiments 
upon which these assertions are based were too complex to give prac- 

1 Therapeutic Gazette, October, 1893. 



198 DRUGS 

tical results; and second, because his own studies and those of others 
show the vasomotor system to be depressed. There is of course some 
cardiac enfeeblement and dilatation, which add to the fall of pressure. 
As with other discussions in medicine, the truth of the question as 
to whether chloroform causes death by respiratory failure or cardiac 
failure lies, as it were, half-way between the two antagonistic opinions ; 
and, further than this, the somewhat startling statement may be made 
that it is not directly due, in the majority of cases, to either of these 
causes. On the contrary, the cause of death from chloroform is usually 

Fig. 29. 



I m 1 1 1 i i i i i i i i i i 1 i i i 1 i i i i 1 i n 1 n i i i i i ti i 11 i i i i i i i i n i t i i i i n i i i i i i i i 1 i i i i 



M ^ /WV WWVVVVVVY^^ 

1 l I 1 I 1 I ' I 1 I l l I I I I l I I I l l I I I 1 I I l l I i i I I I I i I i i i i i i i i i i I i i l i I i i i i i i 




Tracings showing the pulse and blood-pressure depressed by chloroform. Note the fall of 
blood-pressure which begins in the upper tracing and becomes marked in the second tracing. 
Also notice the weak pulse shown in the third tracing, illustrating the final depressant effect of 
the drug on the heart. The respiration ceased at X, but the heart continued to beat. The 
blood-pressure failed first, then the pulse, then the respiration, and last of all the heart stopped. 
(Reduced from natural size.) 

vasomotor depression, whereby the arterioles allow the blood to pass too 
freely into the great bloodvessel areas which exist in the capillaries and 
veins, and as a result the man is suddenly bled into his own vessels as 
effectually as if into a bowl. When it is remembered that the capil- 
lary network of the body will, with the relaxed veins, hold many times 
the normal quantity of blood, and when it is remembered that we can 
inject salt solutions into the vessels to the extent of several times the 
normal quantity of blood without raising the blood-pressure, it at once 
becomes evident that the complete vascular relaxation caused by chloro- 
form results in failure of all the vital functions, not because the drug 
has paralyzed the heart or respiratory centre, but because these parts 
are deprived of blood by its stagnation in the widely dilated capillaries 
and abdominal veins. Studies by Leonard Hill on The Physiology 
and Pathology of the Cerebral Circulation show that this is the case, 
for he asserts that when the blood is no longer flowing to the re- 



CHLOROFORM 199 

spiratory centres the heart is still beating, because its coronary 
arteries, being lower down, are more easily supplied by the small blood- 
stream received by the heart from the veins. These studies are proved 
by the experiments of the author and his assistant, Dr. Thornton, 1 by 
every tracing of the Hyderabad Commissions, and all other tracings 
we have ever seen. Lockhart Mummery has also shown that if a 
dog is beheaded and pithed, and life maintained by artificial respira- 
tion, that it is impossible to stop the heart with chloroform given 
in an ordinary dose. Even when the air supplied to the lungs was 
completely saturated with heated chloroform so that the heart was 
stopped, it could always be revived, showing that it was not truly 
poisoned or destroyed in function by this drug. We may conclude, 
therefore, that while chloroform without doubt acts as a powerful 
depressant poison to the respiratory centre and the heart in the same 
manner as it paralyzes all living protoplasm when applied in excess, 
that when properly given by inhalation it produces a death equivalent 
to that resulting from hemorrhage, which is a failure of the respira- 
tion not so much frc a a direct depression of the respiratory centre 
as from its deprivation of blood; and while the tendency of the drug 
is to depress and dilate the heart, just as it dilates the vessels of which 
the heart is merely a highly specialized part, the failure in the pulse is 
due to vasomotor palsy, the patient becoming pulseless because the 
heart has no blood to pump. 

Let us see what evidence supports this view: First, we have the 
laboratory tracings of many independent investigators extending over 
many years and made in all parts of the world, all of which show a fall 
of blood-pressure. Among these may be named Bowditch and Minot, 
of Boston; Coats, H. C. Wood, Gaskell and Shore, the Hyderabad 
Chloroform Commissions; the studies of Wood and the author in 1889 
and 1890, and of the author and Thornton in 1892 and 1893. They are 
confirmed by Hill, who has seen the abdominal vessels engorged with 
blood under chloroform, the medulla almost bloodless, and the heart 
still pumping, though respiration had ceased. They are confirmed by 
the author's own experiments, in which he proved that even after the 
respiration had stopped and the carotid was empty, and the dog appar- 
ently dead, it could be resuscitated by visceral compression and artifi- 
cial respiration, and by inversion, whereby the blood left the dilated 
abdominal veins for the heart and brain. Again, if a needle was 
inserted through the chest-wall, the heart was found to be beating, 
for the needle moved to and fro; and finally if the chest was opened 
the heart could still be found beating feebly — dilated, it is true, but 
beating. 

So much for the laboratory evidence. What have we in clinical 
evidence? Equally positive proofs of vasomotor palsy, and none of 
death being purely cardiac or respiratory. For years Chisolm, of Balti- 

1 Therapeutic Gazette. October, 1893. 



200 DRUGS 

more, and later Howard Kelly and a large number of others have used 
inversion with compression of the floating ribs in artificial respiration, 
which has forced the blood into the chest and saved life again and 
again. For years the literature of medicine has teemed with reports of 
death from chloroform while the patient was sitting up or half recum- 
bent, because, the blood-paths being dilated, this posture favored anaemia 
of the vital centres. Again, it has been proved that one of the best vaso- 
motor stimulants — belladonna or atropine — given before the chloro- 
form is used increases the safety of the patient, and that compression 
of the limbs by bandages does likewise. Recent studies by means of 
the sphygmomanometer on human beings have also shown a marked fall 
of blood-pressure when chloroform is inhaled even in moderate amount. 
Finally, Hill has shown that abdominal compression also aids resuscita- 
tion by forcing the blood to the heart. On the contrary, saline transfu- 
sion, which would seem to be indicated, is useless, because the dilated 
blood-paths will receive the saline for a long time before they will over- 
flow toward the heart, for as fast as the fluid flows in they dilate. 

The author, therefore, believes that while chloroform in its general 
depressing power depresses all vital functions, it is the question of blood- 
pressure which is most important in the healthy individual, although 
the heart may fail if it be damaged by disease before the drug is used. 
Embly, too, has shown that when anaesthesia is first induced the vagus 
centres in the medulla are irritated and may arrest the heart tempo- 
rarily, an arrest which, combined with a sharp fall of pressure, may 
render the arrest permanent. Therefore, in the use of chloroform, 
we should always keep the head low, precede its use by atropine hypo- 
dermically, bandage the limbs if the case is feeble or already bloodless, 
and, if necessary, place compresses on the belly and press them deeply 
into the abdomen if failure of the circulation develops. 

The primary action of the chloroform is to depress the blood-pressure 
chiefly by its vasomotor effect, secondly by its cardiac effect, and 
finally, while the drug does exercise a depressant effect on the respira- 
tory centre, the failure of this centre is chiefly due to anaemia. As, 
however, an intact respiratory centre means regular breathing, we 
watch this function to determine the dose of chloroform actually inhaled, 
and because any variation in this function, as shown in irregular breath- 
ing, means that the chloroform is disordering arterial tension. Death 
from chloroform in a healthy organism, then, is usually a vasomotor 
death, for an intact arterial system is as important to vital function as 
an intact cardiac apparatus. 

Temperature. — Chloroform when taken by inhalation distinctly 
lowers the body temperature, probably by aiding in the dissipation of 
heat and by its action on the nervous mechanism of heat production. 

Elimination takes place by the lungs and by the kidneys, and goes 
on very rapidly, owing to the great volatility of the drug. (See " Effects 
on Nervous System.") 

If large amounts are eliminated by the kidneys, these organisms are 
apt to become irritated and inflamed. 



CHLOROFORM 201 

Antiseptic Power. — Chloroform, when it is added to organic fluids, 
prevents all changes which depend upon the growth of micro-organisms. 

Therapeutics. — The first and most important use of chloroform is 
as an anaesthetic, and at this point we come to a question which has 
been for many years a matter of contention between different sections 
of the medical profession — namely, as to whether its use is dangerous. 
In the Southern and Western parts of the United States chloroform is 
nearly always used, but in the Eastern and Northern portions it is 
rarely employed. Southerners certainly seem to take chloroform 
better than Northerners or those living on the Atlantic coast. It is 
impossible to go into a general discussion of this question here ; suffice it 
to state that even the most enthusiastic supporters of the use of chloro- 
form confess that it is a more dangerous drug than ether if carelessly 
used, and, while the advantages of chloroform are many, this one great 
disadvantage overshadows them all. 1 The advantages are — its more 
agreeable odor and the fact that it does not irritate the air-passages, 
owing to the small amount necessary to cause anaesthesia; the fact 
that its use is less apt to be followed by nausea and vomiting; the 
rapidity of its action; and the small bulk which has to be carried by the 
surgeon. Its disadvantage is — the possibility of its killing the patient. 

We come, then, to the all-important questions: 

1. Is chloroform a safe anaesthetic? 

2. Are we to watch the pulse or respiration during the use of the 
drug, and what are the signs in the respiratory function indicative of 
danger to the patient? 

3. What is the true cause of death from chloroform? 

4. Is death from chloroform possible when it is properly admin- 
istered? 

5. Under what circumstances is the surgeon to use chloroform in 
preference to the less dangerous anaesthetic, ether? 

6. What is the best way of administering chloroform? 

To the first question the answer is, Yes for the majority of cases, 
provided it is given by one who is skilled in its use, and not only knows 
how to giye it, but also how to detect signs of danger. It is not so 
safe as ether at any time, other things being equal, and never safe in the 
hands of a tyro. 

To the second question the answer is, Watch the respiration, because 
as soon as enough chloroform is used to endanger the circulation the 
respiration will show signs of abnormality either in depth, or shal- 
lowness, or irregularity. In other words, the very effect of the drug- 
may be to cause such deep and rapid respirations that an excessive 
quantity of the drug is taken into the lungs and continues to be 
absorbed even after the inhaler is withdrawn. 

As there is always a fall of blood-pressure under chloroform, it is 
difficult to feel the radial or temporal pulse, and the respiratory centre 

1 The mortality based upon many tens of thousands of cases in which chloroform has 
been used is about 1 in 2039 (Gurlt) ; or according to the combined statistics of Julliard 
and Ormsby, in 676,767 administrations there were 214 deaths — 1 in 3162. 



202 DRUGS 

recognizes the degree of arterial depression which its sister vasomotor 
centre has permitted by finding that its blood-supply is insufficient. As 
respiration fails first, it should be watched first. It is only by watching 
the respiration that we can tell how much chloroform the patient is 
getting. We do not watch this function for danger alone, but to 
determine the dose. 

Everyone is agreed that the patient taking chloroform should have 
plenty of fresh air, and in India, to all intents and purposes, patients 
are operated on in the open air, at least as compared to the closed 
rooms necessary in America and Europe. This free supply of air is 
important whether death is believed to be imminent from cardiac or 
respiratory failure; but this supply of air matters little to the patient if 
he does not breathe freely, nor does the quantity of chloroform amount 
to aught if it is not drawn into the lungs. The dose of chloroform is 
not the amount on the inhaler, but the amount taken into the lungs, 
and, finally, the amount absorbed by the bloodvessels. The rapidity 
and depth of respiratory movements is, therefore, as Lawrie asserts, 
the key to the situation. We withdraw chloroform, as Lawrie says, 
whenever respiration becomes disturbed in rhythm or when struggling 
disturbs it, because it is the first indication that the drug's action is 
uncertain, and because there is no means of determining the dose which 
is absorbed. While watching the respiration will not warn us of a sudden 
cardiac arrest in fatty heart plus chloroform depression, neither will the 
pulse give us such warning; and we are confident that the statement 
of the Hyderabad Commission, that the respiration should be watched, 
is correct, for we believe, from a series of observations that gradual 
cardiac failure never occurs without producing respiratory changes 
from the very first. In other words, we do not believe that in a 
healthy heart chloroform can cause serious disorder without, as a 
result of beginning disorder, disturbing respiration; and, second, that 
in the healthy heart a quantity of chloroform sufficient to disorder 
it will by its direct action disorder the respiration, If, as an extra 
precaution, one assistant watches the pulse while another watches 
the respiration, very well, for though the respiration is the more 
important function to watch, the person watching the pulse might dis- 
cover an irregularity which the ansesthetizer may not see reproduced 
in the respiratory action; but as divided attention generally means a 
slighting of both objects in view, Lawrie is right in insisting on the 
pulse being ignored. 

The answer to Question 3 is that death is always due in the healthy 
person to vasomotor failure accompanied by respiratory depression, 
the vascular relaxation being severe enough to cause death even if 
artificial respiration is used skilfully. 

The answer to Question 4 is, Yes. The physician having a case of 
heart disease requiring surgical interference should always advise the 
patient of the danger of an anaesthetic, and he should remember, 
whether it is wise to tell the patient or not, that ansesthesia always means 
an approach to death even in the healthiest of men. In the event of 



CHLOROFORM 203 

a death under chloroform the physician is blameless if he has taken 
suitable preliminary precautions and given the chloroform properly. 

To Question 5 we have several answers to make: 

1. Chloroform may be used in hot climates (when ether is inapplic- 
able), where a free circulation of air increases the safety of the patient. 

2 Chloroform may be used whenever a large number of persons are 
to be rapidly anaesthetized, so that the surgeon may pass on to others 
and save a majority of lives, even if the drug endanger a few, as on 
the battlefield, where only a small bulk of anaesthetics can be carried. 

3. The employment of chloroform is indicated in cases of B right's 
disease requiring the surgeon's attention, owing to the fact that anaes- 
thesia may be obtained with such a small quantity of the drug that 
the kidneys are not irritated, whereas ether, because of the large 
quantities necessarily used, would irritate these organs. Quantity for 
quantity, ether is, however, the less irritant of the two. 

4. In cases of aneurism or atheroma of the bloodvessels, where 
the shock of an operation without anaesthesia would be a greater 
danger than the use of an anaesthetic, chloroform is to be employed, 
since the struggles caused by ether and the stimulating effect which it 
has on the circulation and blood-pressure might cause vascular rupture. 

5. In children or adults who already have bronchitis, or who are 
known to bear ether badly, or, in other words, have an idiosyncrasy 
to that drug, chloroform may be employed. 

Other indications for the use of chloroform in preference to ether are 
in the performance of brain surgery, where ether is apt to produce 
meningeal congestion by vomiting. In performing tracheotomy, if 
the case is urgent and the ether produces respiratory irritation, chloro- 
form may be used with advantage. 

Chloroform inhalations have been recommended in excessive chorea 
and in puerperal convulsions, and are of great service in the reduction 
of hernia, owing to the muscular relaxation produced. 

Sometimes a few whiffs will put a nervous patient to sleep, but its 
use as a hypnotic is very dangerous, as it may produce a habit, and 
the habit is apt to end fatally. 

Parturient women seem able to take chloroform with more safety than 
other women. There are four important factors in lessening the 
danger of chloroform in this class of cases: 1st. Less chloroform is 
given than is usual in surgical operations. 2d. The pregnancv mav 
produce immunity by reason of the slight cardiac hypertrophy pro- 
duced at this time. 3d. The absence of fright, for the woman welcomes 
the anaesthetic. 4th. The frequently recurring pains of labor so 
stimulate the vasomotor centre that the dominant action of chloroform 
— namely, vasomotor depression — is combated. 

In severe whooping-cough a few drops of chloroform may be poured 
on the hand of the attendant and the hand held before the child's face. 
While the child may at first dislike the odor of the drug, the relief given 
soon teaches the patient its value, and he will ask for it when he feels 
the attack coming on. If the attack is prolonged and violent, this 



204 DRUGS 

treatment must be used with caution, owing to the strained condition of 
the heart-muscle, which may be still further depressed by the frequent 
use of the drug. The drug should not be poured on a cloth, but on the 
nurse's hand. In this way too much of it cannot be given to the patient 
at one time. 

Administration. — When chloroform is given it should be poured 
drop by drop upon an Esmarch inhaler, or upon a folded napkin or 
towel, in which case the cloth should then be held about three to six 
inches from the mouth and nose, so that the vapor may be thoroughly 
mixed with air in the proportion of 2 per cent, of vapor to 98 of air; 
0.5 per cent, does not cause unconsciousness and 5 per cent, is dangerous. 
The British Special Chloroform Committee (1910) points out that in 
grave disease and feebleness less than 2 per cent, should be used to 
avoid danger, and in persons of this type even so low a percentage as 0.5 
will prove efficient. The percentage to be used is that which is adequate 
and does not exceed 2 per cent. Two per cent, should not be exceeded 
at any time during its use. The character and form of the material 
used to cover the inhaler or to hold the chloroform is of greater import- 
ance than would appear at first sight.. Thus, a single layer of flannel, 
although it holds less chloroform than will several layers, nevertheless 
may provide the patient with a greater amount of chloroform, because 
under these conditions the air is drawn through the meshes of the flannel 
instead of over its surface, as it is when the several thicknesses prevent 
the through-and-through passage of air. Again, the degree to which 
chloroform spreads when poured on different fabrics is of some interest. 
It spreads more rapidly over loosely woven cloths than over tightly 
woven ones, and so exposes a greater surface for vaporization and 
permits a greater dose of chloroform per inhalation not only by this 
means, but by the fact that air is readily drawn through its meshes. 

The anaesthetist should never permit himself to hurry the patient 
under the effect of the drug nor should he permit any preliminary 
measures or the primary incision to be made until the patient is well 
under. Many deaths have resulted from carelessness in these par- 
ticulars. 

The administration must be gradual, as "pushing" the anaesthetic 
is dangerous. The best way to use the drug is by means ofa" chloro- 
form dropper ampoule," which is so constructed that it falls upon the 
inhaler drop by drop. 

The safest method of administration is by Esmarch 's or Lawrie's 
inhaler, because these provide a free circulation of air and the atten- 
tion of the ansesthetizer is not distracted from the respiratory move- 
ment by the manipulation of complicated apparatus. 

The dangers of chloroform seem to be considerably decreased by 
the simultaneous administration of oxygen gas with the anaesthetic 
vapor. (For the best method of using oxygen and chloroform together 
see Oxygen, Important.) 

The author largely agrees with Lawrie's published conclusions, 
which are as follows with slight modifications: 



CHLOROFORM 



205 



1. The chloroform should be given on absorbent cotton, stitched 
in an open cone or cap. 

2. To insure regular breathing, the patient, lying down, with the 
clothing loose about the neck, heart, and abdomen, should be made to 
blow into the cone, held at a short distance from the face. The right 
distance throughout the inhalation is the nearest which does not cause 
struggling or choking or holding of the breath. 



Fig. 30. 




Esmarch's inhaler and chloroform bottle. The inhaler consists of a wire frame covered 
by a piece of thin flannel. 

3. The administrator's sole object while producing anaesthesia is 
to keep the breathing regular. As long as the breathing is regular 
and the patient is not compelled to gasp in chloroform at an abnormal 
rate, there is comparatively little danger. 

4. Irregularity, of the breathing is generally caused by insufficient 
air, which causes the patient to struggle or choke or hold his breath. 
There is little or no tendency to either of these untoward effects if 
sufficient air is given with the chloroform. If they do occur, the cap 
must be removed and the patient allowed to take a breath of fresh 
air before the administration is proceeded with. 

5. Full anaesthesia is estimated by insensitiveness of the cornea. 
It is also indicated by stertorous breathing or by relaxation of the 
muscles. Directly the cornea becomes insensitive or the breathing 
becomes stertorous inhalation should be stopped. The breathing 
may become stertorous while the cornea is still sensitive. The rule to 
stop the inhalation should, notwithstanding, be rigidly enforced, and 
it will be found that the cornea always becomes insensitive within a few 
seconds afterward. 

Above all, it is necessary to remember the fact that a person hav- 
ing taken chloroform twenty times before does not show he is not 
in danger on taking it the twenty-first time; and it is also to be borne 



206 DRUGS 

in mind that many of the sudden deaths from chloroform have occurred 
during the first stage of the inhalation of the drug before conscious- 
ness has been lost, and, therefore, when an accident was least expected. 
In operations about the mouth chloroform may be employed by 
passing a soft catheter through the nose and then by means of a hand- 

Fig. 31. 




Lawrie's collapsible inhaler, made of four small pieces of bamboo covered with muslin. The 
chloroform may be dropped on the sides of the inhaler. 

bulb attached to a small wash-bottle containing chloroform, or by 
means of a Junker inhaler, introducing into the post-nasal spaces 
chloroform vapor mixed with air. 

Some of the evil effects of chloroform can be avoided if the physician 
in charge of the case will not only attend to the state of the stomach and 
bowels, but the cardio-vascular state as well. Given a patient who is 
suffering from arterial spasm and fibrosis, there can be no doubt that 
he will pass through chloroformization far better if for several days 
before the use of the drug he have rest in bed and a course of one of 
the nitrites. So too, in cases in which hypotension is present, a course 
of cardiac tonics and the use of strychnine hypodermically to combat 
vascular relaxation is advantageous, 

It is often a good plan to give atropine hypodermically before 
using chloroform, in order to avoid relaxation of the splanchnic ves- 
sels, but the preliminary use of morphine is usually unwise. The 
danger of an accident is greatly increased if the patient is placed 
in the Trendelenburg posture. 

Individuals who are robust and strong and who struggle violently are 
in greater danger from the use of chloroform than the sickly and weak, 
probably because the struggles cause deep inhalation of the drug, ex- 
haust the vasomotor system, strain the heart and tend to dilate its walls, 



CHLOROFORM 



207 



Fig. 32. 




The question has arisen a number of times whether it is possible to 
chloroform a person who is asleep without his being awakened. This 
has been decided by numerous tests to be possible, particularly if the 
sleep be heavy. 

Before closing the consideration of the use of chloroform for anaes- 
thetic purposes mention should be made of the so-called ansesthetic 
mixtures. Of these the A. C. E, is the best known. It consists of a 
mixture of 1 part of alcohol (sp. gr. 0.838), 2 parts of chloroform (sp. gr. 
1.497), and 3 parts of ether (sp. gr. 0.735). Billroth's A. C. E. mixture 
is composed of chloroform 3 parts and ether and alcohol 1 part each. 
The Vienna mixture consists of 1 part of chloroform and 5 of ether, and 
the so-called methylene mixture in 30 per cent, methylic alcohol, and 
70 per cent, chloroform. The object 
of all these mixtures is evident — 
namely, to get the ansesthetic effect 
of the ether and chloroform without 
the cardiac and respiratory effects of 
either, and the alcohol when added 
is to act as a stimulant. As the vola- 
tility of each ingredient varies, the 
mixture is futile, for the ether evapo- 
rates first, and the chloroform next, 
and the alcohol last. The A. C. E. 
is popular in England, but not in the 
United States. 

Chloroform, when taken inter- 
nally by the mouth, causes a sensa- 
tion of warmth in the stomach and 
a hot, burning taste about the lips 
and buccal mucous membrane. In 

when taken in this manner. Comparatively rarely used in internal 
medicine, chloroform in the form of the spirit of chloroform (Spiritus 
Chloroformi, U. S.) or water of chloroform {Aqua Chloroformi, U. S.) 
is useful in cough mixtures, which are given to persons having an irri- 
tative cough, and in cases where, through nervousness or other cause, 
tickling in the throat or bronchial tubes keeps the patient continually 
in a state of unrest. (See Bronchitis.) 

In gastric or intestinal flatulence 1 or 2 minims (0.05-0.10) of pure 
chloroform, or 30 to 60 minims (2.0-4.0) of the spirit of chloroform, 
will often give relief. The following prescription is useful in all forms 
of abdominal pain and is harmless in ordinary dose: 

1^ — Spiritus chloroformi f oss (16.0). 

Spiritus camphora? foij (8.0). 

Tincturse lavendulse composite q. s. ad f oiij (90.0). — M. 
S. — Dessertspoonful (8.0) in water every twenty minutes for 4 doses. 

In the treatment of serous diarrhoea the spirit of chloroform when 
combined with astringents and opium is most useful, provided that 
the irritating cause is first removed. In renal or hepatic colic a few 



Krohne and Seseman's modification of 
Lawrie s inhaler, with feather respiration- 
indicator attached. The inner lining is of 
white felt, the outer case is of leather. The 
chloroform may be poured on the felt 
through a small hole in the leather on the 
top of the inhaler. 

overdose it has produced death 



208 DRUGS 

inhalations, not sufficient to disturb consciousness, will not only give 
temporary but sometimes permanent relief by relaxing spasm. Hypo- 
dermic injections of 10 to 15 drops (0.60-1.0) of pure chloroform, 
reaching down to a painful sciatic nerve, have been recommended by 
Bartholow. This is a very painful treatment, and may cause a slough. 
Rubbed on the chest in the form of chloroform liniment, this drug will 
sometimes prevent asthmatic attacks, but chloroform ought not to be 
inhaled, except most carefully, in this affection, because of the strained 
condition of the right side of the heart. 

In drachm (4.0) doses chloroform has been used as a remedy for 
tape-worm, but. ought never to be so employed. 

When placed in liniments of a stimulating character chloroform is 
a very useful application over muscles affected by soreness and stiff- 
ness, as in lumbago and gout, and chloroform liniment may also be 
used over neuralgic areas for its local anaesthetic effect. 

Fig. 33. 




Showing the attitude in which the head should be held to permit the easy passage of air 
through the glottis. This position raises the epiglottis and lifts the soft palate from the tongue. 
(Martin and Hare's method.) 

Contraindications. — Chloroform is not to be used in cases of fatty heart 
or dilatation of the heart, in those with a known idiosyncrasy, nor in 
iso-called lymphatic persons with overgrowth of lymphoid tissue, as, 
for example, adenoids. In the latter class it is particularly apt to cause 
sudden death. In valvular disease of the heart chlorofom may be 
used with caution, although ether is preferable. Given a case of 
valvular disease that must be subjected to operation, the chances are 
better with an anaesthetic, as the pain and mental shock are worse 
for the heart than is the anaesthetic. (See Suprarenal Gland.) 

Untoward Effects and their Treatment. — Vomiting after the use of 
chloroform develops in about 15 per cent, of cases. Alarming effects 
produced by this drug are far more apt to appear in males than in 
females, the relative proportion being about 6 to 1. Sometimes during 
the administration of chloroform the heart or respiration suddenly 
ceases, and in some cases this change is preceded by a peculiar shade 



CHLOROFORM. 



209 



or cloud which passes over the face of the patient; but death may 
come suddenly and without warning. If untoward effects appear, the 
anaesthetic must be at once withdrawn and artificial respiration re- 



Fig. 34. 




Shoeing the inversion of the patient as adopted by Kelly, and the method of performing 
artificial respiration simultaneously. The chest is expanded by drawing its lower segment 
toward the operator. 



sorted to. Injections of ether and brandy should be given beneath 
the skin, and the poles of a battery with a rapidly interrupted current 
swept over the body, but not held over the phrenic nerve or diaphragm. 1 

1 While few text-books give any specific directions concerning the practical application of the 
methods which are to be employed in such emergencies, those that do so force the physician to a 
procedure at once dangerous and impractical; for the directions usually given are, to place the 
positive pole of the battery on the phrenic nerve as it crosses the anterior scalene muscle at the 
root of the neck, the negative pole being pressed against the lower margin of the ribs. A rapidly 
interrupted current is now to be used with the purpose of causing contraction of the diaphragm 
by the direct action of the electricity upon the nerve. Even theoretically this is a possible source 
of danger, and practically the writer has proved danger to be ever present under such treatment. 
The cardiac inhibitory nerves run so closely to the phrenic fibres, and respond so readily to elec- 
trical stimulation, that it is difficult to imagine how they can escape stimulation if a current be used 
of sufficient strength to excite the phrenic nerves near by. By practical experiment the writer 
has proved that inhibition of the heart may not only be possibly brought about by this method, 
but also that it is nearly impossible to avoid such an effect if the phrenics are to be reached. 
14 



210 



DRUGS. 



The patient must be held head downward, so that the blood will flow 
to the brain, as Leonard Hill and the author have shown that the 
chief cause of death is vasomotor relaxation with accumulation of the 
blood in the abdominal vessels. Bandages should be applied to the 
limbs and compression, by means of a bandage and large compress, be 
exercised on the abdominal contents, and active artificial respiration 
practised for a long period of time as the most important measures 
for the patient's relief. External heat should be applied. Atropine, 
strychnine, and digitalis may be used to stimulate the heart and respi- 

Fig. 35. 




Same as Fig. 34, except that the floating ribs are compressed to expel the air from the chest. 

ration. Of these, strychnine is the most valuable. (See directions 
under the article on Ether.) Adrenalin chloride, according to recent 
investigations, seems contra-indicated in that it increases the danger 
of ventricular fibrillation. (See Suprarenal Gland.) 

In addition to the movements of artificial respiration, the tip of the 
tongue may be grasped by a pair of forceps and drawn out of the mouth 
and upward from ten to fourteen times a minute, in order to stimulate 
the diaphragm. (See Asphyxia, Part IV, for detailed directions.) In 
a number of cases patients apparently dead from chloroform have been 



CHLOROFORM 211 

resuscitated by repeated massage of the praecordium, and even by incis- 
ing the abdominal wall and massaging the heart through the diaphragm. 

The measures adopted for resuscitation should not be stopped for 
at least one hour, as individuals have recovered as long as this after 
an accident from chloroform. 

Ostertag has found that very prolonged inhalations of chloroform 
in the lower animals produce widespread fatty degeneration. 

Caspar, in 1850, and, more recently, Guthrie, in England, and Bevan 
and Favill, in America, and an increasing number of other observers 
have published researches in which they found that anaesthetics, espe- 
cially chloroform, can produce a destructive effect upon the cells of the 
liver and kidneys, and on the cells of the heart and other muscles, 
resulting in fatty degeneration and necrosis, very similar to the effects 
produced in phosphorus-poisoning. These changes are most marked 
in the liver. Further, they are in direct proportion to the amount of 
the anaesthetic employed and the length of the anaesthesia; and again, 
certain individuals exhibit an idiosyncrasy or susceptibility to this effect 
of chloroform. Of the predisposing causes, they find that children are 
more susceptible than adults; that conditions of lowered vitality, such 
as diabetes, infections, and intoxications, predispose to it, and, indeed, 
any condition which tends to produce exhaustion, as do also sclerotic 
changes in the liver and kidneys. As a result of this fatty degeneration 
of the muscle and liver cells, toxins are produced which are ordinarily 
eliminated, but which in certain cases are retained, and these toxins 
produce a definite chain of symptoms which appear in from 10 to 150 
hours after the anaesthesia, and consist in vomiting, retching, delirium, 
convulsions, coma, Cheyne-Stokes respiration, cyanosis, jaundice, 
and usually death. A certain number of mild cases are met with in 
which a transient jaundice occurs and in which recovery takes place. 
Bevan and Favill consider that the hepatic changes are as definite 
as those found in the pancreas in acute pancreatitis, and that, as by- 
products in this toxaemia, but not as the essential poisons, are found 
acetone diacetic acid, and beta-oxy butyric acid in the blood and 
urine. They assert that the damage to the liver may be so great as to 
cause a total destruction of this organ, and they state that this serious 
and evil late effect of chloroform, which has heretofore not been 
generally recognized, must still further limit the use of this powerfnl 
and dangerous agent. They believe that diabetes, sepsis, starvation, 
hemorrhage, and fatty degeneration contraindicate the use of chloro- 
form, and that the possibility of this condition arising also mili- 
tates against the employment of chloroform in prolonged operations, 
particularly in children. If acetone is found in the urine, the use of 
chloroform is contraindicated. 

When acetonuria is found after the use of chloroform, the patient 
should be treated as if he had diabetic acetonuria. (See Diabetes.) 
Bicarbonate of sodium, given in full doses, may be used as a prophy- 
lactic measure for several days before operation when this complication 
is feared, and large doses are advantageous to combat the condition 



212 DRUGS 

when it is present. Glucose may also be used in doses of \ ounce (15.0) 
in water by the stomach after this viscus has been washed out with a 
solution of sodium bicarbonate. A drachm is the dose of glucose for a 
child. If the state is very urgent, the glucose may be given intravenously 
in normal salt solution. 

There can be no doubt that the danger of acidosis resulting from the 
use of chloroform is greatly increased by starving the patient before the 
anaesthetic is given, and it has been proved that the use of easily as- 
similated or predigested starchy foods shortly before the production 
of anaesthesia probably greatly decreases the danger of this grave com- 
plication, just as full amounts of carbohydrate food are indicated in 
cases of diabetes threatened by diabetic coma. 

Local Use and Internal Administration. — The official preparations of 
chloroform are a liniment (Linimentum Chloroformi, U. S. and B. P.), 
a water (Aqua Chloroformi, U. S. and B. P.), dose J to 2 ounces 
(16.0-60.0); a spirit (Spiritus Chloroformi, U. S. and B. P.), the dose 
of which is 20 minims to 1 fluidrachm (1.3-4.0). The B. P. recognizes, 
besides those given, Tinctura Chloroformi et Morphince Composita, dose 
5 to 15 minims (0.3-1.0). 



CHROMIUM TRIOXIDE. 

Chromic acid (Chromii Trioxidum, U. S. ; Acidum Chromicum, B. P.) 
is not a true acid, but an anhydride, and occurs in the form of brilliant 
red crystals, which are deliquescent and possess a sour, metallic taste. 
The acid should be kept in glass-stoppered bottles. It should never 
be mixed with sweet spirit of nitre, strong alcohol, or glycerin, or any 
organic matter, as under these circumstances an explosion may 
result. 

Therapeutics. — Chromium trioxide is used solely as a caustic for the 
destruction of groivths on the skin or mucous membranes. When a 
limited area is to be destroyed, a small crystal is placed on the part to 
be cauterized; but if a larger area is to be attacked and severe action 
is required, the liquid resulting from its deliquescence on exposure to 
the air may be employed by means of a glass rod. The surrounding 
tissues should always be protected with lard or adhesive strips. 

J. William White has recorded a death from the application of 
chromium trioxide to a large number of condylomata about the buttocks 
and vulva. Where the drug has been swallowed, the patient should 
be treated for gastro-enteritis, and dilute alkalies and lime-water be 
used, as well as emetics and demulcent drinks. 

If a superficial action is desired, a solution containing 100 grains 
to the ounce (6.6-30.0) of water is sufficient, and for small warts and 
similar growths this solution will be found sufficiently strong. 

Liquor Acidi Chromici, B, P v is composed of 1 part of acid to 3 of 
water, 



CIMICIFUOA. 213 

CHRYSAROBIN. 

Chrysarobin (Chrysarobinum, U. S. and B. P.) is a neutral principle 
derived from a powder found in the wood of the tree Vouacapoua 
araroba, which was originally used for medicinal purposes in Brazil. 
In the East Indies it is called "Goa powder." Chrysarobin is some- 
times misnamed chrysophanic acid, and is a yellow, tasteless powder, 
soluble in solutions of alkalies, in acids, and in ether. 

Therapeutics. — Chrysarobin is given internally in the dose of J- 
grain (0.008) in psoriasis and parasitic diseases of the skin, but more 
commonly is employed externally in the form of the official ointment 
(Unguentum Chrysarobini, U. S. and B. P.), which is too strong for 
direct use, and should be mixed with 4 or 5 parts of benzoated lard 
before application to the skin. Even when so diluted, chrysarobin 
may cause great swelling and inflammation of the skin, with desqua= 
mation of the cuticle. Should the surface be broken, the drug may be 
absorbed and cause vomiting. As chrysarobin stains the skin a dark 
brown, it ought not to be used on the face; but should this accident 
occur, the discoloration may be removed by the application of a 
weak solution of chlorinated lime. In psoriasis the following may be 
employed after the patient has taken a bath to soften the scales: 

1$ — Chrysarobini oj (4.0) 

^Etheris, 

Alcoholis . . aa q. s. ut ft. sol. 

Collodii f Sij (60.0).— M. 

S. — Apply with a brush to the part affected. 



CIMICIFUGA. 

Cimicifuga (U. S.) is derived from Cimicifuga racemosa, other- 
wise known as black cohosh or black snake-root. It contains a resin 
and a volatile oil, upon which its medicinal powers are supposed to 
depend. The fluidextract and tincture should always be freshly pre- 
pared from the fresh crude drug. 

Physiological Action. — In large doses cimicifuga paralyzes the sensory 
side of the spinal cord of the lower animals, and in consequence 
lowers reflex activity. It has no effect on the nerves and muscles. 
On the circulation the drug acts by depressing the heart and vasomotor 
system. Death is due to respiratory arrest. In small dose it is a feeble 
cardiac stimulant. When full medicinal doses are given to man it 
nearly always produces frontal headache. Its known physiological 
effects have no direct bearing upon its use in medicine. 

Therapeutics. — Cimicifuga is, excepting arsenic, the best remedy we 
have for chorea, particularly if the patient is otherwise in good health, 
but it should be used with careful attention to the regularity of the 
bowels and often be accompanied by iron. It is also indicated when 
there is, in addition to St. Vitus's dance, a rheumatic tendency. In 



214 DRUGS. 

chronic bronchitis it is asserted to be of value, and in rheumatism of a 
subacute or chronic type cimicifuga sometimes gives relief. 

Cimicifuga has been highly praised in the treatment of neuralgia, 
particularly of the ovarian type, and in amenorrhea, subinvolution 
and tenderness of the womb. To women who state that they cannot 
step off a step without paining or hurting the uterus or ovaries cimi- 
cifuga often gives relief. Some writers assert that it is an efficent 
heart tonic in cases of fatty and irritable heart when digitalis fails. 
There can be no doubt that it is an active uterine stimulant, and it 
ought to be used with caution during pregnancy for fear of abortion. 
There are, however, some practitioners who commend its use for the 
prevention of this accident. By reason of this power it may be employed 
instead of ergot during labor, and is said to be better in some cases, 
because it produces normal, not tonic contractions. As a matter of 
fact, it is little used for this purpose. In the treatment of headache 
arising from overstraining of the eyes cimicifuga is said to be bene- 
ficial. 

The drug is official as the extract (Extractum Cimicifuga 7 , U. S.), 
dose 1-5 grains (0.06-0.3), the fluidextract (Fluidextr actum Cimi- 
cifugce, U. S., the dose of which is 10 to 30 minims (0.60-2.0) or even 
1 drachm (4.0). 

CINCHONA. 

Cinchona, U. S., is the dried bark of Cinchona ledgeriana, Moens, 
Cinchona calisaya, Weddell, Cinchona officinalis, Linne, and of hybrids 
of these with other species of cinchona (Fam. Rubiacew). It should 
yield not less than 5 per cent, of cinchona alkaloids. 

It occurs in quills or curved pieces of variable size, usually 2 or 3, 
sometimes 5 mm. thick; externally gray, rarely brownish-gray, with 
numerous intersecting transverse and longitudinal fissures, which have 
nearly vertical sides; the outer bark may be absent, the color externally 
being then cinnamon-brown; inner surface light cinnamon-brown, finely 
striate; fracture of the outer bark short and granular, of the inner 
finely splintery; powder light brown or yellowish-brown; odor slight, 
aromatic; taste bitter and somewhat astringent. Cinchona Rubra, 
U. S., Cinchona Rubra Cortex, B. P., is the dried bark of Cinchona 
succirubra, Pavon (Fam. Ruhiaceoe), or of its hybrids, yielding not 
less than 5 per cent, of alkaloids of red cinchona when assayed by the 
process given for these alkaloids under Cinchona. 

The alkaloids of the quinine series derived from these barks are 
quinine or quinina, quinidine or quinidina, and quinicine, which is 
an artificial alkaloid. Of the cinchonine series we have cinchonine, 
cinchonidine, and cinchonicine, which last is also an artificial alkaloid. 
Besides these alkaloids there are present kinic and kinovic acids and 
other inert and useless substances. 



CINCHONA 215 

As quinine is the most important of the group, and as its physio- 
logical action is virtually identical with that of the rest, whatever is said 
hereafter in this article refers to quinine unless otherwise stated. All 
the alkaloids of cinchona which have been named are not employed as 
pure alkaloids, but as salts formed by adding sulphuric, hydrochloric, 
or other acid to increase their solubility. 

Physiological Action. — When quinine is taken in overdose, it causes 
ringing in the ears, dizziness, disorders of taste and smell, disturbance 
of vision in some cases, and fulness in the head. Deafness often 
comes on, and is generally, with the roaring in the ears, the most annoy- 
ing symptom. Headache is not uncommon. (See Untoward Effects.) 

Nervous System. — Upon the cerebrum quinine acts as a stimu- 
lant, and finally as a congestant if given in excessive dose. If poison- 
ous doses are used, intense cerebral congestion ensues, and finally 
unconsciousness comes on. On the spinal cord of the lower animals 
the drug first causes a decrease in reflex action by stimulating, 
Setschenow's reflex inhibitory centre, and finally by depressing the 
spinal cord and nerves. The latter changes occur only after poisonous 
doses. 

Circulation. — If quinine, even in small amount, be injected into 
the jugular vein of a dog, so that it goes in concentrated form to the 
heart, cardiac paralysis will result. If this does not occur, the drug 
simply decreases pulse-force, pulse-rate, and arterial pressure. When 
given to man in small medicinal doses by the mouth, the drug acts as a 
general stimulant to the entire body, and so tends to support the circu- 
lation, increasing to a slight degree the pulse-rate and blood-pressure. 
If the dose by the mouth be very large (15 grains), the pulse is depressed. 
Full doses in fever therefore act as vascular sedatives. 

Blood. — After poisonous doses the blood is more coagulable than 
normal, but in medicinal amounts no such effect is produced. The 
effect of quinine on the blood-corpuscles is of great interest. Even 
in full medicinal doses it arrests diapedesis of the white cells from the 
capillaries by a direct action on these cells, and if the drug be applied 
to the mesentery of a frog the cells already extruded cease their move- 
ment, but the intravascular cells do not. On the other hand, if qui- 
nine be given internally in so small a dose that the proportion to the 
blood is as 1 to 20,000, the white cells in the vessels cease to migrate, 
but those cells in the surrounding tissues do not (Binz, Hare, Dissel- 
horst, Ikeda). It is stated, however, that this is not the case with all 
animals. This is perhaps the explanation of the effects of quinine in 
acute inflammations, for it arrests inflammatory exudation and allows 
the extruded cells to wander from the diseased area. Wilson and also 
Mainwaring and Ruh have shown that small doses of quinine equalling 
2 to 3 grains of the sulphate distinctly increase the phagocytic power of 
the blood, and that very large doses, more than 4 grains, circulating in 
the blood, distinctly decrease this power. This is another scientific 
confirmation of the belief of many practitioners that quinine aids the 



216 DRUGS. 

body in combating infections. Medicinal amounts gradually increase 
very materially the number of red blood corpuscles in man. 

Respiration. — Upon respiration quinine acts as a slight stimulant 
in small doses, but as a marked depressant in poisonous amounts. 

Temperature. — Quinine lowers body temperature in health very 
little if at all, and in fevered states its influence is governed by the 
cause of the fever. Thus in malarial fevers quinine is a powerful 
indirect antipyretic, by reason of its peculiar powers over the infec- 
tion, and not because it has any direct influence over heat production 
and dissipation. 

Absorption. — Quinine is absorbed from the stomach, not from the 
intestine, and it is precipitated by the alkaline juices of the bowel. 
For this reason it should be given in cachet, capsule, or powder, 
rather than in compressed tablet, so that it may be absorbed by the 
stomach before it reaches the intestine. Only pills which have been 
freshly made should be employed. 

Kidneys, Elimination and Tissue-waste. — Quinine escapes from 
the body chiefly through the kidneys, although some of it is destroyed 
by oxidation in the liver and tissues. In the urine it is found as 
quinine and as dihydroxyl quinine. The excretion of quinine is by 
no means rapid. Thus Jeanselme and Dalimier have shown that 
when it is given intravenously it appears in the urine at once and is 
present in this fluid for approximately twenty-seven hours. When 
given intramuscularly it appears in fifteen minutes and continues 
present for fifty hours, and given by the mouth it appears in the urine 
in twenty-five minutes and persists for thirty hours. This test can 
be made by means of Tanret's solution 1 if the urine is filtered and does 
not contain albumin, and will respond in the presence of T -J-g- mg. Ten 
cubic centimeters of urine are placed in a test-tube and the reagent 
added drop by drop. The urine containing quinine, or its derivative, 
becomes opalescent, then opaque and finally flocculi are deposited. 

Upon tissue-waste quinine acts as a depressant and decreases the 
elimination of nitrogenous materials. 

Digestive Tract. — Quinine has a bitter taste in as small a pro- 
portion as 1 : 10,000 of water. Upon the stomach it acts as a tonic and 
stimulant, but if given too frequently, or in large doses, it may irritate 
this viscus. Moderate doses are slightly constipating, and very large 
doses may induce colicky pain. 

Poisoning and Untoward Effects. — Severe poisoning from quinine 
rarely occurs, except in persons who have an idiosyncrasy to the drug. 
Roberts has recorded the case of a woman, aged thirty-six years, who 
took 5 drachms (2D Gm.) and survived, after suffering from deep 
coma, shallow breathing, slow pulse, absolute deafness, and blind- 
ness. The loss of sight lasted two weeks, but the retinal changes 
persisted for several months. Death from an overdose of quinine is 

1 Tanret's solution is composed of potassium iodide 3.32, mercuric chloride 1.35, 
acetic acid 20 and distilled water 64. 



CINCHONA. 217 

exceedingly rare. The eases in which death has followed its use are 
medical curiosities. Bouchardat has recorded the case of an adult 
male who died as a result of taking from 45 to 65 grains of the drug. 
That this was the real cause of death is doubtful. Soullier quotes 
Tarnier and Budin as asserting that enough quinine may be elimi- 
nated by the milk to produce death in a nursling. This seems hardly 
possible. 

"Untoward effects" is the best term with which to qualify the dis- 
agreeable symptoms which sometimes come on in persons having an 
idiosyncrasy to the drug and who are in reality poisoned by small 
doses. In these cases, sudden, complete, but temporary blindness 
is met with. De Schweinitz has seen it occur after a dose of 15 grains 
given in divided doses during twenty-four hours. He has also shown 
that in dogs quinine produces in continued toxic doses constriction 
of the retinal arteries, and permanent optic atrophy; and Holden has 
proved that there is degeneration of the nerve-fibres and ganglion 
cell-layers of the retina. When the dose is a single one recovery of 
vision usually occurs, but if the quinine has been continued after the 
symptoms appeared the progress is not favorable. In other instances 
complete deafness asserts itself, due to congestion of the middle ear, 
while skin eruptions, generally of the nature of erythema, are not 
rarely seen. In other instances petechial and vesicular eruptions 
are developed, and swelling of the gums with a tendency for them 
to bleed may appear (Schulz). After lethal doses hemorrhage into 
the middle ear may be found, and severe epistaxis may ensue after 
so small a dose as 4 grains (0.25). The buzzing in the ears can gener- 
ally be relieved by the administration of 10 grains (0.60) of bromide 
of sodium combined with a little ergot. Karamitsas has stated that 
quinine may produce hemoglobinuria in persons suffering from 
malarial poisoning, and apparently may even develop bilious remit- 
tent fever. 1 (See below.) Irritability about the neck of the bladder 
may sometimes be produced by quinine, particularly in children. 

Therapeutics. — Quinine is employed in medicine to fulfil one great 
office, although its influence in other directions is by no means slight, 
namely, to destroy the malarial parasite. It may also be employed 
as an antipyretic, and as a tonic possessing peculiar virtues. 

For many years physicians employed this drug empirically, not 
knowing the cause of the disease called malaria. We now know that 
the theory of Binz, advanced as long ago as 1867, is correct, and that 
malaria is due to the presence of a parasite, the ylasmodium malaria, 
which was first accurately studied by Laveran and named by Marchia- 
fava and Celli. These and other investigators have found that quinine 
acts as an active poison to these parasites, even in so weak a solution as 
1:20,000. The direct effect of quinine upon the three forms of the 
malarial parasite has been studied by a number of investigators, chiefly 

1 See collective investigation of this subject by the author in Therapeutic Gazette for 
July, 1892; also article in New York Medical Record, January 7, 1899. 



218 DRUGS. 

by Romanowski, Mannaberg, Marchiafava, and our own Craig (U. S. 
Army). Craig states that if quinine is given when the young intracor- 
puscular parasites of the tertian variety are present there at once fol- 
lows a great increase in amoeboid movements, followed in an hour by 
an arrest of this movement. The parasite now becomes ring-shaped, 
or spherical, and much more sharply outlined than in the parasite not 
affected by the drug, and its protoplasm becomes very refractive and 
granular. In those parasites which succeed in advancing to the stage 
of segmentation in spite of the quinine the young segments undergo 
fragmentary degeneration. The effect of quinine upon the full-grown 
tertian parasite before segmentation takes place is to cause the organism 
to shrink, to become granular, and the pigment bodies to become mo- 
tionless. An important practical therapeutic fact is that if one large 
dose is given just before a chill it destroys many of the young para- 
sites, but if not all these then those which escape rapidly attack new 
blood cells; whereas if repeated doses of quinine are given every three 
or four hours all the parasites are destroyed. 

When the quartan parasite is attacked by quinine the same quicken- 
ing of amoeboid movement, followed by arrest and by fragmentation 
and granular degeneration, ensues, but the young parasites seem to be 
more susceptible, so fewer escape than in the case of the tertian or- 
ganism. 

As to the sestivo-autumnal parasite, Craig states that the hyaline 
or "ring" forms become very much more refractive and sharply 
defined under the effect of quinine. Their amoeboid movements are 
greatly increased and they move rapidly from one place to another in 
the red cell. Marchiafava and Bignami assert that they even escape 
from the red cell. Fragmentary degeneration of the sestivo-autumnal 
parasite is said not to occur. In this type of infection the use of quinine 
at regular intervals of three or four hours is particularly important. 

When malarial patients relapse the cause lies in improper use of 
the drug, or to the fact that some of the parasites are hidden in the 
bone marrow or spleen, or to the fact that by frequent small doses the 
parasite has become immune to quinine. Ehrlich states that in the 
latter cases an injection of neosalvarsan will at once. cure the patient. 

For the reasons given in the preceding paragraphs quinine is the 
best remedy for malarial fever as a prophylactic and cure, and it 
should be given in doses which are indicated by the state of the patient. 
(See Administration and Intermittent Fever.) If possible it should 
always be preceded by a purge having an hepatic action. This 
preliminary treatment is particularly important in bilious or remittent 
fever. The drug should be given in one or two large doses in such a 
way that its influence is fully exercised, not only at the time of the 
expected paroxysm, but about an hour or thirty minutes before that 
time and every four hours thereafter. If the paroxysm is near at 
hand, the drug should be given in solution, bitter though it be, in 
acidulated water. If the attack be so far advanced as the sweating 



CINCHONA. 219 

stage, it should be given, nevertheless, to destroy the spores just set 
free. (The student must read the article in Part IV, on Intermittent 
Fever at this point.) 

As a prophylactic against malaria the dose of quinine should be 2 
to 4 grains (0.12-0.25) or more three times a day, but in this use of 
it there is danger of producing a strain of parasites immune to quinine 
and, therefore, difficult to eradicate. (See Intermittent Fever.) 
This is important to remember not only from the stand-point of the 
individual patient but in respect to "carriers" since from them the 
mosquito may spread the infection to others. 

In hemorrhagic malarial fever quinine sometimes seems to do more 
harm than good. Under such circumstances the danger in using 
quinine consists in irritating the engorged kidneys after the chill has 
passed. Quinine is not a haemostatic, and only does good in malarial 
hematuria by destroying the parasite which produces the bloody 
urine. In hematuria occurring in persons broken in health as a result 
of chronic malarial infection, quinine is of no value unless an exami- 
nation of the blood reveals the presence of parasites. To give quinine 
after this symptom appears is to "lock the door after the horse is 
stolen" unless the parasites are found in the blood. Many studies in 
America, Greece, and Italy indicate that the use of quinine is capable 
of developing a hematuria. 1 (See Hematuria.) If, however, an 
examination of the blood reveals the malarial parasite, the drug 
should be freely used. Malarial hemoglobinuria is probably not caused 
by quinine, but is probably due to an associated parasite. 

In pernicious malarial fever quinine should be given by the mouth, 
as much as 60 to 70 grains (4.0-4.6) being used, or intramuscularly 
and intravenously. (See Administration and Intermittent Fever.) 

For the reduction of the pyrexia of typhus or typhoid fever quinine 
is inferior to the new antipyretics, even when given in very large 
dose, and it ought to be used rarely, if at all, for this purpose. In 
all fevers it will seldom cause a fall of temperature before crisis or 
lysis, but will aid in the fall very actively after these changes have 
begun. In those cases of fever in which the use of quinine is fol- 
lowed by marked improvement the good results are due either to its 
specific antimalarial influence or to its stimulating influence on the 
general system. 

As a tonic quinine acts not only as a simple bitter, but also seems to 
have a direct effect in increasing the number of the red blood corpuscles. 
The tonic dose should be 1 to 2 grains (0.06-0.12) three times a day. 

Quinine has been used to overcome uterine inertia in weak women, 
but it is a feeble remedy, and is seldom resorted to by progressive 
obstetricians. (See Kola.) Indeed some obstetricians believe that 
it increases the danger of post-partum hemorrhage. It will not of 
itself cause abortion, but in nervous, hysterical women who have a 

1 See collective investigation of this subject by the author in Therapeutic Gazette for 
July, 1892; also article in New York Medical Record, January 7, 1899. 



220 DRUGS. 

tendency to abort, and to whom it is necessary to give full doses of 
quinine during pregnancy, it may be well to combine some sedative, 
as one of the bromides or opium, with the antiperiodic. 

In cases where prolonged mental or -physical strain is to be under- 
gone, quinine in the dose of 2 to 4 grains (0.12-0.25) will often prevent 
exhaustion and support the system. 

The internal use of quinine is a wise procedure in whooping-cough, 
and the proper dose, according to a careful series of studies by Baron, 
is 1J grains (0.08) for each year of the child's age, to be given at 
6 a.m., 2 p.m., and 10 p.m. 

A much more agreeable method of pursuing this treatment in 
whooping-cough is to give the patient the so-called quinine chocolates, 
which contain 1 grain (0.06) of tannate of quinine and chocolate in 
each. The taste of quinine in such chocolates is scarcely noticeable 
if they are well made, although the after-taste is bitter. 

Used in solution in the form of a spray by the atomizer, quinine is 
of undoubted service in whooping-cough, and will often prevent the 
spread of the disease to other children if they be subjected to its use. 
This solution should contain from 1 to 2 grains (0.06-0.12) to the 
ounce (30.0) and be employed every few hours. As Mallory and 
others have shown that the germ of whooping-cough grows in the 
epithelial cells at the root of the tongue the quinine may exercise a 
direct germicidal effect. The bitter taste can be to some extent dis- 
sipated by the use of a cream peppermint drop before and after 
treatment. 

High rectal injections of quinine in the strength of 1 : 3000 are 
useful in amebic dysentery, as this drug destroys the Amoeba coli. 
Rogers and other eminent Oriental practitioners advise that in amebic 
abscess of the liver the pus be removed by aspiration and the cavity 
filled by the injection of a solution of 30 to 40 grains (2.0-2.6) of 
bihydrochloride of quinine. By this means the cavity usually sterile 
except for the amoeba is kept sterile, and the patient avoids a serious 
operation when exhausted. 

Quinine and urea hydrochloride has been proved to possess marked 
power in the production of local anaesthesia in five to twenty minutes 
when injected in solution into subcutaneous or submucous tissues. 
It may also be applied in solution to mucous membranes for this 
purpose. The anaesthesia may last from four to six hours or even 
several days when the drug is injected. For operative work it is 
employed in exactly the same manner as cocaine. It seems very 
efficient and is not as toxic as is cocaine. (See Coca.) The strength 
of the solution for infiltration anaesthesia varies from 0.25 to 1 per cent., 
the weaker one usually giving the best results, as the stronger one 
sometimes causes the formation of an indurated area where injected. 
For local application 10 to 20 per cent, solutions are employed. Solu- 
tions ready for hypodermic use are now placed on the market in 
sterile ampoules. 






CINCHONA 221 

Administration. — When prescribing quinine the physician should 
employ the hydrochloride (Quinince Hydrochloridum, U. S. and B. P.), 
as it contains a high percentage of alkaloid and is very soluble in 1 to 
18 of water. An acid hydrochloride {Quinince Dihydrochloridum, U. 
S., Quinince Hydrochloridum Acidum, B. P.) is also official, and possesses 
the advantage that it is soluble in less than its own weight of water. 
The hydrochloride of quinine is stronger in alkaloid than the bisulphate 
of quinine (Quinines Bisulphas, U. S.), which is, however, soluble in 
the proportion of about 1 to 9.0 of water. The hydrobromide of 
quinine (Quinince Hydrobromidum, U. S.) is another useful salt, which 
is soluble in the proportion of 1 to 40 of water. The valerate of quinine 
(Quinince Valeras) possesses no particular value. Quinince Salicylas, 
U. S., is also official. The sulphate of quinine (Quinince Sulphas, 
U. S. and B. P.), the least soluble of all these salts, is by custom most 
commonly administered. Quinince T annas, U. S., is a salt not so 
bitter as the other salts, and is weaker in relative alkaloidal strength. 
One grain (0.06) of the tannate equals about J grain (0.015) of pure 
alkaloid. The bisulphate equals about § and the sulphate J grain 
of the pure alkaloid. The dose of the salts of quinine varies from 1 to 
to 4 grains. (0.06-0.25) as a tonic, and from 4 to 60 grains (0.25-4.0) 
for antimalarial purposes. 

The B. P. recognizes a pill of quinine, Pilula Quinince Sulphatis, 
a tincture ( Tinctura Quinince), a wine (Vinum Quinince), and an ammo- 
niated tincture (Tinctura Quinince Ammoniata). 

In regard to the administration of quinine, it may be said that it 
ought never to be given in solution if it can be avoided, because of its 
disagreeable taste, but if its prompt absorption is essential this is the 
best way to use it. If it is given in solution, the liquid should be well 
acidulated, as under these circumstances it will not taste so bitter as 
when a weakly acidulated solution is employed and it is more rapidly 
absorbed. In adults and children quinine should be used preferably 
in small capsules or in pills, which may be gelatin-coated or sugar- 
coated. Another means for adults is the use of cachets. If pills 
are employed, care should be taken that the sugar is not hardened by 
age, and if capsules are used that the gelatin is thin, for if the pill or 
capsule escapes into the intestine before it is dissolved the quinine is 
precipitated and is not absorbed. If the case is that of a child too 
young to take a pill, the drug may be given in the following manner 
without tasting very disagreeably : 

1^ — Quininse hydrochloridi gr. xvj (1.0). 

Fluidextracti glycyrrhizse f§j (4.0). 

Syrupi aurantii fgij (60.0). — M, 

S. — A teaspoonful t. i. d. for a child of three years. 

Tannate of quinine chocolates may be used, but even if they are 
well made the after-taste of quinine is marked. The rectal use of 
quinine is hardly justifiable, Little is absorbed and rectal irritation 
is prone to occur. 



222 DRUGS. 

Quinine should be given by the hypodermic needle only when the 
infection is so severe as to endanger life or when the stomach is too 
irritable to retain the drug, but if the need is so urgent the intraven- 
ous method is preferable. (See next page.) If given hypodermically, 
the injection should be intramuscular, because it is less prone to cause 
abscess and severe pain, and also because it will be more rapidly 
absorbed from the muscular tissues than from the subcutaneous tissues. 
One of the great muscles of the back is to be chosen. When given by 
the needle the best salt is the dihydrochloride, often called the acid 
hydrochloride, which is very soluble (about 1 part to 1 of water). 
The ordinary dose when given in this manner is 10 grains (0.65). The 
greatest possible precautions as to the maintenance of rigid asepsis 
of the skin, the needle, the syringe, the solution, and even of the 
salt itself is essential to avoid abscess. Further, the solution must 
not be concentrated, but dilute, because in concentrated solution 
quinine damages the tissues and destroys the phagocytes which 
ordinarily hurry to a damaged area to destroy any pathogenic organ- 
isms which may gain access to the devitalized spot. In India a 
considerable number of cases of tetanus have followed the intramuscu- 
lar use of quinine. A useful way of using this salt is to employ a 
solution in sterile water put up in glass ampoules, ready for use, con- 
taining about 4 grains (0.25) each, or 

fy — Quininse hydrochloridi gr. iiiss (0.15). 

Urethani gr. ij (0.06). 

Aquae destillatse f3j (4.0). — M. 

This solution is said to keep indefinitely. 

When the dihydrochloride is not at hand, the hydrochloride of 
quinine may be used, as it is soluble in about 18 parts of water, and 
contains more of the alkaloid than the more soluble bisulphate of 
quinine. It may be employed in the following manner: 

1$ — Quininse hydrochloridi gr. vij (0.5). 

Glycerini, 

Aquas destillatse aa f5ss (2.0). — M. 

S. — Warm solution before using it, and do not add acid. 

1$ — Quininse hydrochloridi gr. xv (1.0). 

Alcoholis Mlxv (1.0). ' 

Aquse destillatse . . . f3iss (6.0). — M. 

S. — Add a drop of dilute hydrochloric acid to complete solution before using. 

If the bisulphate is used intramuscularly, to its solution should be 
added a little tartaric or sulphuric acid to prevent precipitation of the 
drug in the alkaline juices of the connective tissue before it can be 
absorbed. The tartaric acid should be present in the proportion of 
about 1 grain (0.06) to each 5 grains (0.3) of the quinine. The hydro- 
bromide of quinine, the solubility of which is about 1 to 40 of water, 
may also be used intramuscularly, as may also the bimuriate of quinine 
and urea (Quinines et Urece Hydrochloridum, U. S.), which, however, is 
scarcely more than half as strong in quinine as the other salts. All 
of these injections are painful except the last. 



CINCHONA. 223 

Baccelli used the intravenous injection of quinine in severe cases 
of malarial infection. He employed the following solution for this 
purpose : 

1$ — Quininae hydrochloridi gr. xv (1.0). 

Sodii chloridi gr. xv (1.0). 

Aquse destillatae . . fgiiss (10.0).— M. 

S. — This should be injected, after an ounce (30.0) of distilled water has been 
added to it. The solution should be boiled and filtered, and used while warm. 

McLean, Michael and other surgeons in the United States Navy 
have strongly advocated the intravenous injection of strong quinine 
solutions in malaria and even in cases of malarial hematuria in which 
the parasite is found in the blood. The dihydrochloride may be 
dissolved in sterile water so that each mil. contains 1 grain. Of 
this solution 10 or 15 mils. (10 or 15 grains of the drug) are injected 
in each dose. The solution should be freshly prepared and well 
sterilized. The needle is then inserted through the wall of a vein 
distended by the use of a tourniquet, the skin being first painted with 
tincture of iodine. As soon as blood appears, proving the vein has 
been entered, the syringe, which has been previously charged, is attached 
and the fluid injected very slowly. A sense of flushing of the surface 
of the body ensues sometimes accompanied by dizziness. Some head- 
ache may develop. The patient should lie down for a few minutes. 
Doses may be given once or twice a day. Less reaction, due to the 
small amount of water used, is met with than when bulky solutions are 
employed. 

Sulphate of cinchonidine (Cinchonidince Sulphas, U. S.) is very 
useful in influenza combined with salicin or one of the newer salicylates. 

The dose of quinidine sulphate (QuinidinoB Sulphas) is about twice 
that of quinine, as is also that of cinchonine sulphate (Cinchonince 
Sulphas, U. S.) and cinchonidine sulphate {Cinchonidince Sulphas, 
U. S.). 

Chinoidinum is a resinous mass obtained in the preparation of the 
alkaloids of cinchona, and contain amorphous alkaloids. It possesses 
distinct antiperiodic power, and was used freely when quinine was a 
very expensive drug. Its dose is three or four times that of quinine. 

The liquid preparations of cinchona are the infusion (Infusion 
Cinchona 3 ), dose a wineglassful (30.0); the tincture (Tinctura Cin- 
chona 3 , U. S. and B. P.), one or two teaspoonfuls (4.0-8.0); and the 
compound tincture (Huxham's) (Tinctura Cinchona 3 Composita, U. S. 
and B. P.), a teaspoonful to a tablespoonful (4.0-16.0). Tincture 
of cinchona should contain from 0.8 Gm. to 1.0 Gm. of cinchona alka- 
loids in each 100 mils. Huxham's tincture is a most efficient and 
elegant bitter tonic in debility and convalescence from low fevers 
It is too weak in alkaloids to be used in malarial infection. Lender 
the name of Elixir Roborans, or Whytt's tincture, a similar mixture 
is employed for the same purposes. The other liquid preparation is 
the fluidextract (Fluid extraction Cinchona 3 , U. S., or Extraction Cin- 
chona Liquidum, B, P.), which contains from 4 Gm. to 5 Gm. of the 



224 DRUGS. 

cinchona alkaloids in each 100 mils., dose 5 to 15 minims (0.3-1.0). A 
solid extract (Extraction Cinchona?) is given in the dose of 5 to 10 
grains (0.3-0.6). The B. P. preparation not official in the U. S. P. 
is the Infusum Cinchona? Acidum, dose \ to 1 fluidounce (15.0-30.0). 
Contraindications. — Quinine is contraindicated in gastritis, cystitis, 
meningitis, epilepsy, cerebritis, and middle-ear disease, because it con- 
gests, irritates, or stimulates those areas which are diseased, and is also 
contraindicated in those cases which have an idiosyncrasy to its action. 

C'lNNAMON. 

Cinnamon (Cinnamomum Saigonicum vel Zeylanicum, U. S. ; Cinna- 
momi cortex, B. P.) is the inner bark of a plant, a native of Ceylon 
or of the species indigenous to China. It contains a volatile oil and 
tannic acid. In overdose the oil acts as a soporific and kills by failure 
of respiration. 

Therapeutics. — Cinnamon is used, as are all the drugs of its class, 
for flavoring, as a carminative, and as an intestinal stimulant in serous 
diarrhoeas. It has the peculiar power of acting as a hemostatic in 
uterine hemorrhage where the flow is oozing and not active, thereby 
differing from the other volatile oils, with the exception of that of 
erigeron. The oil of cinnamon is a powerful antiseptic, which can be 
used in dilute form in the dressing of wounds and by injection in 
gonorrhoea. 

Cinnamic acid, a derivative of oil of cinnamon, is also used for the 
same purposes; but its chief employment has been in the treatment of 
tuberculosis. This consists in injecting hypodermically and intramus- 
cularly 2 minims (0.1) of the acid. The injection produces burnirg 
pain, which soon disappears. The patient, however, feels fatigued, has 
vertigo and cerebral congestion. Gradually the dose is increased to 
15 minins (1.0), and after several weeks the patient is said to cough 
less, to gain in weight, and to improve in physical signs. The treat- 
ment is so painful that it has not gained favor. 

Administration. — The dose of the oil (Oleum Cinnamomi, U. S. 
and B. P.) is 1 to 5 minims (0.05-0.3); of the water (Aqua Cinna- 
momi, U. S. and B. P.), a wineglassful (30.0) or less; of the spirit 
(Spiritus Cinnamomi, U. S. and B. P.), 5 to 30 minims (0.3-2.0): 
of the tincture (Tinctura Cinnamomi, U. S. and B. P.), \ to 1 drachm 
(2.0-4.0). Under the name of Pulvis Aromaticus, U. S. (Pulvis 
Cinnamomi Compositus, B. P.) a carminative powder, consisting of 
cinnamon 35 Gm., nutmeg 15 Gm., cardamoms 15 Gm., and ginger 
35 Gm., is official. The B. P. preparation does not contain nutmeg. 
Aromatic powder is useful in the treatment of the flatulence of adults 
and children. The latter should take about 10 grains (0.60) at a dose, 
an adult 30 grains (2.0). 

Pulvis Aromaticus also enters into the composition of Fluidextr actum 
Aromaticum, U. S., which is given in the dose of 10 to 60 minims 
(0.6-4.0). 






CLOVE. 225 

CITRIC ACID. 

Citric acid (Acidum Citricum, U. S. and B. P.) is chemically iden- 
tical with the acid of the lemon, but has not identical influences upon 
the body with lemon-juice. It is a tribasic organic acid usually pre- 
pared from the juice of limes or lemons and should not contain less 
than 99.5 per cent, of pure citric acid. It occurs in colorless, trans- 
lucent, right-rhombic prisms; odorless; having an agreeable, purely 
acid taste ; efflorescent in warm air, and deliquescent when exposed to 
moist air. 

Citric acid is soluble in 0.5 part of water, and in 1.8 parts of alcohol 
at 25° C. (77° F.); in about 0.4 part of boiling water, and in 30 parts 
of ether. Not only does the lemon owe its acidity to this acid, but 
most of the other edible fruits, such as strawberries and raspberries, 
depend upon its presence for their acidity. 

Therapeutics. — Citric acid is used in scurvy, or scorbutus, as a pro- 
phylactic and cure. For some unknown reason, pure lemon-juice 
seems to benefit these cases more than citric acid itself, and it is, there- 
fore, to be preferred to the latter whenever it can be had. In order 
to keep lemon-juice from decomposition on long voyages, it should be 
boiled and poured while hot into bottles until it nearly reaches the 
cork; the remaining space is then filled with a thin layer of hot sweet 
oil and the bottle corked and stood upright. Under these circum- 
stances the juice may be kept indefinitely. 

Wright claims that because of the excess of calcium salts in cows' 
milk its prolonged use may predispose cases of typhoid fever to throm- 
bosis by increasing the coagulability of the blood. Five grains of 
citric acid given several times a day may be used to prevent this state, 
since it diminishes this tendency by removing the excess of calcium. 
If, however, the citric acid is used too constantly, it has been found 
that it may also increase the coagulability of the blood. For this 
reason it should be used every second or third day and not every day. 
Addis claims that Wright's views are erroneous, and the matter is still 
to be decided. 

In rheumatism, either acute or chronic, lemon-juice may be em- 
ployed in the dose of 1 to 2 ounces (30.0-60.0) four times a day, well 
diluted, or 2 drachms (8.0) of citric acid may be given. The acid is 
also of value in hepatic inactivity and catarrhal jaundice. (See Citrate 
of Potassium.) 

The preparations containing citric acid are Syrupus Acidi Citrici, 
U. S.; Succus Limonis, B. P., and Syrupus Limonis, B. P. 

CLOVE. 

Clove (Caryophyllus, U. S.; Caryophyllum, B. P.) are the dried 
flower buds of Eugenia aromatica, a plant of the East and West Indies. 
They possess an aromatic odor and the pungent taste of a typical 
15 



226 DRUGS. 

spice. They contain a volatile oil (Oleum Caryophylli, U. S. and 
B. P.), which is yellow when fresh, but very dark in color when old. 
It should contain 80 per cent, of Eugenol, U. S. 

Therapeutics. — Clove, or its oil, is used in medicine for its car- 
minative effect. It is also employed as a stimulant and tonic to the 
stomach, to prevent griping during an attack of diarrhoea, or that 
caused by purgatives, to act as a flavoring agent, as a counterirritant, 
as a parasiticide, and as a local anaesthetic. 

The oil of clove possesses great power for good in many cases of 
pulmonary tuberculosis when cough and expectoration are excessive, as 
it greatly diminishes the quantity of sputum expectorated. It should 
be given in the dose of 5 minims (0.3) in capsule 1 hour after food 
three or four times a day, or a hypodermic injection of sterilized 
almond oil, containing in each dose of 30 minims (2.0) 5 minims (0.3) 
of the oil of clove, should be administered once a day. The injection 
should be given into the subcutaneous tissues of the flank or abdomen, 
and is painful, but the decrease in the cough and expectoration amply 
repays the patient for the pain. 

Like all volatile oils, this oil is an efficient local application for 
Pedicidosis pubis and similar parasites. It may be used in toothache 
because of its anaesthetic powers, placed on a pledget of cotton in 
the cavity of the aching tooth. In the treatment of my alia or mus- 
cular rheumatism, oil of clove is often placed in a liniment for its 
counterirritant effect. Doses of | to 1 minim (0.03-0.06) of the oil in 
a little water will sometimes control excessive vomiting. In addition 
to the oil the B. P. has an official infusion, Infusum Caryophylli, 
the dose of which is \ to 1 fluidounce (15.0-30.0). 

In overdose oil of clove acts as a soporific, and kills by failure of 
respiration and the production of severe gastro-enteritis. 

COCA AND COCAINE. 

Coca is the dried leaves of Erythroxylon coca, Lamarck (Fam. 
Erythroxyl&G?) , known commercially as Huanuco coca, or of Erythro- 
xylon truxillense, Rusby, known commerically as Truxillo coca, which 
yields, as a rule, about 0.5 per cent, of the ether-soluble alkaloids of 
coca. Coca in the U. S. P. of 1880 was known as Erythroxylon. 
Cocaine (Cocaina, U. S. and B. P.); Cocaine Hydrochloridum, U. S. 
and B. P.) is the alkaloid derived from Erythroxylon. When cocaine is 
heated with hydrochloric acid it is split into several substances, among 
others a base called ecgonine, which has wholly different properties 
from cocaine, and is perhaps responsible for some of the evil effects 
which have resulted from improperly prepared cocaine. It is to be 
distinctly understood that Erythroxylon coca is not the same as choco- 
late or Theobroma cacao. 

Physiological Action. — Coca and its alkaloid cocaine, when taken 



COCA AND COCAINE. 



227 



Fig. 3ft 




internally, produce in some persons a sense of exhilaration and pleasure. 
Often muscular and mental activity is temporarily increased under their 
influence. When locally applied to a mucous membrane, cocaine 
causes blanching followed later by marked congestion. 

Nervous System. — The dominant action of cocaine, when locally 
applied to the peripheral sensory nerves, is to paralyze them (Fig. 36). 
When taken internally it stimulates the brain to an extraordinary 
degree, but exercises no effect upon the 
sensory nerves unless given in poisonous 
doses. Sometimes its internal use pro- 
duces a decrease of sensation, which 
Mosso believes to be due to an influence 
on the spinal cord. This effect is, how- 
ever, very feeble. If the dose be a poi- 
sonous one, convulsions of cerebral origin 
ensue, and are both clonic and tetanic in 
type. 

Upon the muscles, when taken inter- 
nally, Mosso has proved the drug to be 
a direct stimulant, and it is particularly 
active after starvation or fatigue. Mus- 
cular power is increased temporarily by 
cocaine by setting free reserve energy. 

Circulation. — Cocaine in moderate 
amounts acts as a stimulant to the 
heart and vasomotor centre, but its 
effects are not marked except in almost 
poisonous dose. 

Respiration. — The drug acts as a powerful respiratory excitant, 
producing in large dose a great increase in the rapidity of the respiratory 
movements, but in poisonous dose it kills by failure of respiration 
associated with exhaustion from the accompanying convulsions. 

Temperature. — Cocaine raises bodily temperature to an extra- 
ordinary degree if given in overdose, this rise being due to an increase 
of heat-production (Reichert). In moderate or medicinal amounts 
it has no such effect. 

Kidneys, Elimination, and Tissue-waste. — The drug is elimi- 
nated by the kidneys, but is chiefly destroyed by oxidation in the body. 
Under its influence the quantity of urine passed is increased and the 
nitrogenous elements eliminated in this fluid are slightly diminished. 

Eye. — Owing to its powerful action as a local anaesthetic, cocaine 
has been used largely in diseases of the eye, and it is particularly effi- 
cacious in this organ because of the delicacy of the conjunctiva, which 
it readily penetrates and so paralyzes the peripheral sensory nerve- 
endings. The anaesthesia comes on in from one to five minutes after 
the use of the drug, according to the strength of the solution used. 
When cocaine is applied to the eye, it causes distinct enlargement of 



A, sensory nerve supplying mu- 
cous membrane (B), which is anaes- 
thetized by cocaine, paralyzing the 
ends of the sensory nerve at B when 
locally applied. 



228 DRUGS. 

the palpebral fissure and an apparent prominence of the eyeball. This 
is due to a stimulant effect of the cocaine upon the sympathetic nerve- 
fibers which supply the unstriped muscle-fibers of the lids. Accom- 
panying this effect, there is marked dilatation of the pupil, which 
Roller asserts is due to constriction of the bloodvessels of the iris, 
the muscular fibers being unaffected. Ophthalmologists, however, 
generally assert that this mydriasis is due to the fact that the drug 
stimulates the peripheral ends of the sympathetic nerves. It is impor- 
tant to remember that this dilatation, unlike that produced by mydria- 
tics, such as atropine, is not accompanied by paralysis of accommoda- 
tion, and the dilatation of the pupil can be overcome at once by the 
use of eserine or pilocarpine. The drug does not cause a forcible 
mydriasis, and is never used for the prevention of adhesions in iritis 
unless combined with atropine. 

Therapeutics. — Cocaine hydrochloride (Cocaines Hydrochloridum, 
U. S. and B. P.) is used as an anaesthetic in the eye in the strength 
of from 3 to 5 or more minims of a 1 to 4 per cent, solution. The 
strength of 2 and 3 per cent, is perhaps most commonly employed. It 
is worth remembering that cocaine is soluble in fats, whereas its salts 
are not. Cocaine itself should therefore be used in anaesthetic salves, 
and may be used for this purpose in an oleate (Oleatum Cocaince) 
which contains 5 per cent, of cocaine. The local anaesthetic effect of 
cocaine is materially increased by using adrenalin solution (1:5000 to 
1 : 1000) with it. This combination also decreases the danger of sys- 
temic effects being produced by cocaine, since the constriction of the 
bloodvessels by the adrenalin prevents the absorption of the cocaine. 
This prevention of the dissipation of the cocaine through absorption 
also increases the local anaesthetic effects of the latter drug. 

The conditions indicating its use in the eye are all operations of a 
painful character, and it may also be used for the relief of pain, 
when an acute inflammation or foreign body is causing suffering. The 
following formula will be found useful in these states: 

1$ — Cocainse hydrochloridi gr. viij (0.50). 

Acidi borici gr. vij (0.46). 

Aquae destillatae fgj (30.0).— M. 

S. — Use with a dropper in the eye evety fifteen minutes until relieved. 

Cases of keratitis are recorded in which cocaine has produced per- 
manent corneal opacities, and it may cause dryness and roughening of 
the corneal epithelium even in the normal eye. 

Cocaine is often used in 2 per cent, solution upon cracked nipples 
just before nursing, to relieve pain. The drug must be carefully 
washed off before the baby is put to the breast. It is asserted, how- 
ever, by Guenel and Desamaux that this treatment may permanently 
stop the flow of milk. 

Owing to the density of the mucous membranes of the vagina and 
rectum, cocaine has little effect upon them unless used in 10 per cent. 



COCA AND COCAINE. 229 

solution and freely applied. In the mouth cocaine may be used in 
cases of stomatitis where a spot is to be cauterized and in pharyngitis. 
While it gives much temporary relief in pharyngitis, the subsequent 
effects are often exceedingly disagreeable, the congested area looking 
more angry and being more painful than before. In coryza and hay 
fever a powder consisting of cocaine, morphine, and bismuth in the 
proportion of 1 part each of the two alkaloids and 5 parts of the 
bismuth will often be of service if snuffed into the nostrils. If cocaine 
be applied to a large nerve-trunk, amputation of the tributary limb 
may be performed without pain, but so large an amount of the drug 
must be used that there is great danger of poisoning the patient. 

Cocaine is often used at present in the place of ether in cases 
requiring amputation of the fingers or in cases of minor surgery where 
the action of the drug can be confined to the part injured. A cord 
should be tightly bound around the base of the finger and a 4 to 8 
per cent, solution injected into the part, the ligature about the base of 
the digit being used to prevent hemorrhage and systemic absorption of 
the drug. After the operation is completed slight hemorrhage should 
be allowed to occur, to sweep out the drug and thereby avoid a systemic 
effect. Not more than J grain of cocaine should be injected. When 
operations on a foot or hand have been done under cocaine anesthesia, 
and larger amounts than this have been used, the constricting band- 
age should be allowed to remain in place some time, since the tissues 
destroy the drug, so that when the bandage is removed less is absorbed. 
(Holscher and others.) 

When a limb is to be amputated under cocaine, the main supplying 
nerve should be exposed by the aid of infiltration anaesthesia (see below), 
and then the nerve-trunk is to be anaesthetized by the injection into its 
sheath of so weak a solution of cocaine in normal saline fluid as 1 per 
cent. 

Under the name of "infiltration an&siliesia" Schleich has introduced 
a method of abolishing sensation in localized areas which often gives 
good results for minor operations. He injects into the skin, as super- 
ficially as possible, a sufficient amount of a solution of common salt, 
cocaine, and morphine to produce local oedema, and thereby pressure 
on the nerve-filaments, which are also depressed by the cold liquid 
coming in contact with them. He also believes that the local anaemia 
so caused aids in decreasing sensation. The injection is given so 
gently that a sort of wheal or oedematous spot is produced where the 
incision is to be made. As soon as this spot is developed the needle is 
inserted into its margin and carried under the skin a little farther, and 
then the injection is repeated. In this way the line of an extensive 
incision can be anaesthetized progressively. If deep incisions are 
necessary, the injections are made into the deeper tissues as well. 
The injections must always be made into healthy skin, as if it is 
diseased a slough may result. Schleich asserts that similar injections 
under the periosteum permit of operations on the bones. The anars- 



230 



DRUGS. 



thesia lasts twenty-six minutes, 
as follows: 



The solution is of three strengths 



Solution. 
Cocaine hydrochloride. 
Morphine hydrochloride 
Sodium chloride 
Sterilized distilled water 



gr. iv (0.25). 
gr. h (0.03). 
gr. iv (0.25). 
t'8 iv (120.0). 



II. 
gr. ij (0.12). 
gr. J (0.03). 
gr. iv (0.25). 
f § iv (120.0). 



III. 

.■(0: 

gr. T \ (0.006). 
gr. iv (0.25). 
f o iv (120-0). 



To each of these solutions 3 minims of a 5 per cent, solution of 
phenol are added. The second solution is the one commonly used. 
The first is employed where acute inflammation is present, and the 
third where repeated injections are necessary. (See Fig. 37.) The 




Infiltration anesthesia. The needle is inserted at each successive point as numbered 
until the line of anaesthesia is complete. 

effect of these injections is considerably emphasized if adrenalin 
chloride in the proportion of 1 : 20,000 is added to the mixture. 

For minor localized operations it is very satisfactory; but for long 
and deep incisions it is of little value, as its effects are inadequate 
unless doses so large as to be poisonous are employed, and because 
it in no way diminishes the fear and mental suffering of the patient, 
in whom the dread of the operation is worse than the actual pain. 
Under certain circumstances, however, it may be used in major surgery, 
such as tracheotomy, the removal of small superficial tumors, and in 
those patients who are so profoundly ill that it is dangerous to use a 
general anaesthetic, as, for example, in intestinal perforation in typhoid 
fever, an operation which has been done many times with this method. 
As the operation proceeds the deeper tissues are anaesthetized by 
infiltration if possible, and are cut, not torn, as the tearing produces 



. COCA AND COCAINE. 231 

great pain. Great care is necessary that the fluid injected is sterile. 
(See Procaine.) 

In place of Schleich's fluid the following plan is now commonly 
followed: A tablet containing f grain (0.045) of cocaine hydrochloride 
with 4^ grain (0.00015) of adrenalin chloride is dissolved in 50. mils. 
of normal salt solution. Another similar tablet is dissolved in 100 
mils, of normal saline. The stronger solution is used to infiltrate the 
skin and the weaker to infiltrate the looser and deeper tissues as the 
operation proceeds. Fill a 2 mil. Record syringe armed with a fine 
needle for the injection of the stronger fluid and a 5 mil. Record syringe 
with a large and coarser needle for the weaker fluid. Precede the 
infiltration anaesthesia by half an hour with from 0.1 to \ grain (0.006- 
0.016) of morphine and -%\^ (0.0003) of scopolamine given hypodermi- 
cally, and if the patient is restless or suffers pain during the operation 
repeat this dose. The operator must not hurry but give the injected 
fluids time to act as he proceeds from tissue to tissue. (See Scopol- 
amine-morphine Anaesthesia.) 

Cocaine and eucaine (see also alypin, stovaine, and tropacocaine) 
have been used to produce anaesthesia of large areas of the lower portions 
of the body and limbs by injecting them into the subarachnoidean 
cavity below the termination of the spinal cord by means of a long 
hollow needle, so-called spinal anaesthesia, but, as the toxicity of these 
drugs is greater than some of the other local anaesthetics, they have 
been supplanted by the newer drugs of this class. (See Tropacocaine 
and Novocaine.) 

Internally, cocaine or the fluid extract of coca may be used as a 
temporary supportant and stimulant in low fevers, and in cases where 
great physical and mental strain must be borne. Its use for any 
length of time is dangerous and harmful. Thorington has found 
cocaine of great value in yellow fever as a stimulant for a short time 
and as an anti-emetic. In the vomiting of pregnancy and other forms 
of excessive ernes is it is of great service by depressing the gastric sen- 
sory nerves and thereby decreasing the irritability of the stomach. 

Cocaine is stated to be an antidote to acute morphine poisoning. 

Cocaine is undoubtedly of service in the opium habit, but if con- 
tinuously used soon changes the patient from a morphinomaniac to 
a "coca fiend," and for this reason should not be employed. 

The dose of the fluidextract (Extractum Coca 3 Liquidum, B. P.) is 
from | to 1 drachm (2.0-4.0), and it should contain 0.5 Gm. of ether- 
soluble alkaloids in each 100 mils. The dose of cocaine is from J to 
| grain (0.015-0.03). The other B. P. preparations are Lamella' 
Cocaince, each disk containing -£$■ grain (0.0012) of cocaine hydro- 
chloride, and Unguentum Cocainas and Injectio Cocaines Hypodermica, 
given in the dose of 1 to 10 minims (0.06-0.6). 

The cocaine habit is a condition unfortunately frequently met with 
since the introduction of this drug into therapeutics. It is often com- 
bined with the morphine habit, and sometimes cocaine is employed as 



232 DRUGS. 

a substitute for morphine. The symptoms of the cocaine habit consist 
of marked loss of flesh, disorders of the circulatory system, mental 
failure, and delusions sometimes resembling those of chronic alcohol- 
ism. Often disagreeable hallucinations are present. The habit is 
difficult to cure, for relapses are frequent. The sudden withdrawal 
of cocaine from a patient may result in profound collapse. 

According to Magnan, a pathognomonic symptom of chronic or 
subacute cocaine-intoxication is a sensation under the skin of a crawl- 
ing worm or bug. 

Untoward Effects. — Loss of speech, blindness, nausea and vomit- 
ing, syncope, and unconsciousness have followed the internal use or 
local application of cocaine. Epileptiform convulsions have also 
been noted, while the circulation and respiration have been disordered 
in every possible manner. In many of these cases the urine passed 
after the poisoning has been copious, limpid, and contained albumin. 
Curiously enough, a large number of cases of severe poisoning have 
followed the injection of cocaine into the urethra previous to oper- 
ation for the relief of chronic gonorrhoea or stricture. 

These symptoms may ensue in susceptible persons after the use of 
quantities received with impunity by others. Thus, they have followed 
the instillation of 20 minims of a 10 per cent, solution. 

The hypodermic injection of cocaine as a stimulant sometimes 
causes vomiting. 

Of 250 cases of accidental poisoning arising from the medicinal 
use of the drug but 13 proved fatal. 

The treatment of the poisoning consists in the use of ammonia, 
coffee, strychnine, or ether and alcohol if the symptoms are those of 
depression. If they are convulsive in type, then the treatment to be 
instituted is identical with that of strychnine poisoning (which see). 

Reichert asserts that morphine is the best antidote to cocaine 
poisoning. 

CODEINE. 

Codeina, U. S. and B. P., soluble in water 1 to 120, is.an alkaloid de- 
rived from opium, or is prepared from morphine by methylation. It is 
often contaminated by morphine. The sulphate of codeine (Codeines 
Sulphas, U. S.) is generally used, as it is more soluble than codeine 
itself. Codeine sulphate is soluble in 30 parts of water. Codeine 
phosphate (Codeines Phosphas, U. S. and B. P.) is also official, and is 
soluble in 2.3 parts of water. 

Physiological Action. — Codeine resembles morphine very decidedly 
in its physiological action, the chief difference being that it possesses 
less narcotizing power, but in large amount it more readily produces 
tetanus and final paralysis of the peripheral motor nerves in the lower 
animals (Dott and Stockman). It does not arrest secretion in the 
respiratory and intestinal tract, as does morphine, and therefore does 
not directly check expectoration and is less apt to cause constipation. 



COD-LIVER OIL. 233 

Therapeutics. — Codeine has been highly recommended for years as a 
nerve quietant in nervous cough and in cases where the cough is exces- 
sive in bronchitis and phthisis. In diabetes mellitus some clinicians 
have found it of value, while others have been disappointed in its 
use. It should, however, always be tried in this disease, in the hope 
that it may exercise a favorable effect. When given for obstinate 
cough it should be used in the dose of from \ to 1 grain (0.03-0.05) 
three or four times a day, in the syrup of wild-cherry bark. When 
given for diabetes the dose should be much larger, beginning at 1 or 

2 grains (0.06-0.12), and rapidly increasing it until the glycosuria is 
diminished. Sometimes as much as 20 or 30 grains (1.3-2.0) or more 
may be given daily. The B. P. recognizes a syrup. {Syrupus Codeince 
Phosphatis) given in the dose of 1 to 2 drachms (4.0-8.0). 

COD-LIVER OIL. 

Oleum Morrhuoe, U. S. and B. P., sometimes called Oleum Jecoris 
Aselli, is a fixed oil obtained from the fresh livers of Gadus morrhua, 
or cod-fish. There are several species of cod from which the oil is 
obtained other than the one named, but that given is the chief source 
of supply. The oil is pale or dark according to its freedom from for- 
eign materials. Although the paler oils are generally prescribed, there 
can be little doubt that the darker ones are more medicinally active. 
The most prominent inorganic constituents of the oil are iodine, 
bromine, and sulphuric and phosphoric acids. It also contains more 
or less of the biliary salts. 

Lofoten cod-liver oil, obtained from cod caught near the Lofoten 
Islands, is generally considered the best for medicinal use. 

Physiological Action. — Cod-liver oil depends on a number of sub- 
stances for its peculiar effect. The iodine certainly exerts definite 
alterative powers, and the oil seems peculiarly adapted to digestion 
and absorption, for cod-liver oil passes through animal membranes 
very readily, probably owing to the biliary salts contained in it. 

The oil aids in the maintenance of bodily temperature by its oxi- 
dation, and causes a deposit of fat in the tissues. It also seems to 
influence the blood directly, for clinical observation shows that anaemic 
persons become healthy-looking under its use, and Cutler and Brad- 
ford have found that this apparent improvement is a physiological 
fact, the red corpuscles being always increased. It has been proved 
by experiment that cod-liver oil is more readily oxidized than any 
other oil. 

The belief among physicians that the effects of cod-liver oil are 
dependent upon some peculiar combination of substances has shown 
itself in the attempts of physiological chemists to isolate the combina- 
tion. One of the best results reached is the so-called "morrhuol," 
a crystalline substance containing phosphorus, iodine, and bromine: 

3 to 5 grains of this preparation are said to represent 1 drachm of 



234 DRUGS. 

the pure oil, and it is certainly of value as a medicament in most of 
the states in which the oil itself is used. In " colds" which "hang on" 
and are not readily gotten rid of, morrhuol is best given in capsule or 
pill. This substance is put on the market in gelatin-coated pills or 
capsules. It does not possess the nutritive value of the oil itself. 

Therapeutics. — Cod-liver oil is useful in those persons who have no 
tubercular lesion in the lung or other tissues, but have mucous, mem- 
branes which are very susceptible to disease. This state has been 
called the pre-tubercular stage of phthisis. Cod-liver oil possesses no 
curative power in cases of well-developed and rapid phthisis, and its 
administration in many cases serves only to nauseate the patient or to 
produce an oily diarrhoea through failure of digestion. It does good 
in the early stage of the disease in that it acts as a food peculiarly 
suited to a wasting malady, and its mild alterative effects are also of 
value. It maintains the patient's strength and general nutrition, and 
so favorably influences the pulmonary lesion, provided it can be 
taken in addition to good food. If it destroys the appetite or dis- 
orders the digestion it is very harmful. In chronic rheumatism the 
drug is often of great service, particularly if the disease is largely 
muscular. Skin lesions depending for their existence upon general 
malnutrition and ansemia, often yield to its use. In enlargement of 
of the lymphatic glands, where they are not undergoing acute active 
suppuration, cod-liver oil given internally does good. This is a 
statement requiring explanation. By acute active suppuration is 
meant the early formation of pus or the molecular death of the 
parts — not the slow formation characterized by no active change, but 
represented by cold abscess or old sores. If the suppurative process 
is chronic, the oil does good by maintaining the patient's nutrition. In 
cases of strumous ophthalmia cod-liver oil is of great service. In 
advanced syphilis cod-liver oil is most useful, and in the early stages 
of rickets it ought to be employed. In marasmus, when used by 
inunction, or given internally if the stomach will stand it, it is one of 
the best drugs we have. If a few grains of bile-salts, consisting of 
glycocholate and taurocholate of sodium, be added to each drachm 
of oil, it will be more readily absorbed, from the skin when applied 
by rubbing, or when taken internally. 1 Another method, to aid its 
absorption, is to mix 1 part of liquid soap with 2 parts of the oil before 
it is rubbed into the skin. 

In sciatica and lumbago and in neuralgia cod-liver oil is of service, 
if those disorders are dependent upon anaemia or an impoverished 

1 These salts may be bought, or made as follows: To about 300 mils, of ox-gall is added 
nearly thrice that quantity of ordinary alcohol, and the flask shaken thoroughly. All 
the mucus is now precipitated and the supernatant fluid is filtered. To the filtrate is 
added a large excess of sulphuric ether, and after a time a plaster-like mass forms at the 
bottom of the vessel, which slowly becomes crystalline. These crystals are now placed 
on a filter-paper and washed with a mixture made of ether and sdcohol, equal parts. 
The filter-paper is dried and the substances then seen are the taurocholate and glycocho- 
late of sodium. Having carefully removed these salts from the paper, they are ready for 
use. 



COD-LIVER OIL. 235 

state of the system. In emphysema of the lungs it is said to be of 
value, and certain writers commend its use in gout, although others 
have asserted that it is of no value. Sometimes old persons, whose 
digestion is not disordered and who have no organic brain disease, 
complain of giddiness. The best treatment for this condition, in many 
cases, is cod-liver oil with small doses of quinine, or if these fail ergot 
and one of the bromides may be used. 

Administration. — Owing to its disagreeable taste and smell most 
patients rebel against taking cod-liver oil; but these objections can, 
with a little persistence, be readily overcome, so that finally the patient 
may not object to the remedy, but actually like it. This is particularly 
true of young children. The secret of reaching this much-to-be-desired 
state lies in the use at first of doses which may be dropped into a teaspoon 
and the spoon then gently submerged in a glass of milk. The oil 
floats off onto the milk in a globule in the centre of the tumbler, and if 
the milk be rapidly gulped down without the oil touching the sides of 
the glass, it will not be tasted. The first gulp must be large enough to 
include the oil. The oil may be taken on a full stomach, but as a gen- 
eral rule it is best digested if taken about two or three hours after meals, 
when the gastric contents are about to be passed into the small bowel, 
where the oil is digested ; and if it be immediately followed by a little 
pancreatin, its digestion will be much aided. Other modes of ingestion 
consist in the placing of the oil in whisky or brandy, in the manner 
which has been described with milk. This method possesses the 
advantage that the alcohol by its stimulating effect aids very distinctly 
in the digestion of the oil. Sometimes a pinch of salt placed in the 
mouth before and after the oil is taken aids in masking its taste and in 
its digestion. (See Indigestion.) Oil of eucalyptus in the proportion 
of 1 to 100 of the cod-liver oil will disguise the latter's taste, but many 
persons dislike the eucalyptus more than the cod-liver oil. The 
addition of an equal quantity of glycerin, with \ to 1 minim (0.025-0.05) 
of the oil of bitter almonds to each dose, is often of service. Syrup of 
bitter orange-peel is one of the best masks to its taste. Tomato ketchup 
has also been used with good results. Chewing a piece of smoked 
herring before and after taking the oil is of value to disguise the 
taste in some cases. The oil is readily taken in soft capsules holding 
from J to 1 drachm (1.0-4.0). Few patients are unable to swallow 
such capsules if these are first made slippery by dipping them in 
water. 

Cod-liver oil is most readily digested when given in single nightly 
doses after supper or after a light meal just before going to bed. After 
a few days it may be given after dinner, and in the course of a week 
after breakfast. If the patient is once nauseated by overdoses, it is 
almost impossible to make the stomach retain the oil. If there is diffi- 
culty in digestion, a drachm of ether aids in its absorption or a drink 
of whisky or brandy may be used instead. Often a simple bitter, 
such as a dessertspoonful (8.0) of compound tincture of cardamom, 



236 DRUGS. 

taken in water immediately after the oil is swallowed, aids in its 
digestion. 

A large number of preparations of cod-liver oil are on the market 
in emulsion, pancreatized, and purified till they are nearly tasteless. 
Emulsion Olei Morrhuce containing 50 per cent, of oil, given in the dose 
of 2 to 4 fluidrachms (8.0-16.0). Many of the permanent or perfect 
emulsions contain more Iceland moss or acacia than oil. The pan- 
creatized emulsions are the best if the oil is present in sufficient quantity 
to do good, as the very fact of the oil being artificially emulsified adds 
to its value and makes it possible to put more oil into the emulsion. 
Oil devoid of smell is probably devoid of medicinal value, as all the 
peculiar properties have been " purified" out of it. 

It has been suggested that cod-liver oil be given by the rectum, a 
full dose of pancreatin being mixed with it to increase its assimilability. 
Sometimes creosote is placed in this injection in 5- to 10-minim (0.3- 
0.6) doses to prevent decomposition changes in the oil and, after 
absorption, to act as an expectorant. 

COFFEE. 

(See Caffeine.) 

COLCHICUM. 

Colchicum is the dried corm (Colchici Cormus, U. S. and B. P.) and 
seed (Colchici Semen, U. S.; Colchici Semina, B. P.) of Colchicum 
autumnale, or meadow saffron, a plant of Europe, containing an 
alkaloid, colchicine (Colchicina, U. S.), which may be still further 
changed into colchiceine. The drug is official in the form of the seeds 
and root. Colchici cormus should yield not less than 0.35 per cent, 
of colchicine. Colchici semen should yield not less than 0.45 per cent, 
of colchicine. 

Physiological Action. — Colchicum is a very powerful drug, and when 
locally applied is an irritant to the skin. Taken internally in overdose, 
it severely irritates the gastro-intestinal mucous membrane. 

According to the studies of one of the writer's students — Dr. 
Ferrer y Leon — the drug has little or no effect when given in mod- 
erate dose on the nervous system, circulation, respiration, or tem- 
perature, producing changes in these parts only when given in poi- 
sonous doses. In full doses it greatly increases the flow of bile, and 
may cause bilious vomiting and purging. Jacobi asserts that death is 
produced by respiratory failure, the heart continuing to beat for many 
minutes after respiration ceases. The violent gastro-enteritis which is 
present in colchicum poisoning in man certainly has much to do with 
the usual fatal result. 

Therapeutics. — The employment of colchicum in medicine centres 
around its use in gout and similar states, such as chronic rheumatism. 



COLCHICUM. 237 

It is almost a specific in acute gout, provided that it be pushed until 
it causes slight griping or laxity of the bowels. Colchicum does not 
seem to possess any marked beneficial effect in preventing attacks. 
Indeed, while it relieves one attack it often seems to hasten the onset 
of the next. In acute gout it is usually well to unload the bowels by 
a small dose of compound extract of colocynth, with some hyoscyamus 
added to it to stop griping. Thus 

B — Extracli colocynthidis compositi gr. x vel xx (0.6-1.3). 

Extracti hyoscyami . gr. ij (0.12). — M. 

Fiant pilulae No. iv. 

S. — One as soon as threatened by an attack. 

This pill is particularly needed if constipation be present and the 
belly hard. After this has acted, the colchicum may be given. Thirty 
to 40 minims (2.0-2.6) of the wine of the seeds should be given, and 
20 minims (1.3) more in twelve hours. In some cases of subacute or 
chronic gout or chronic rheumatism, iodide of potassium should be used 
in conjunction with the colchicum. The following may be ordered : 

I$— Po'tassii iodidi 5 ss vel 5 j (2.0 vel 4.0). 

Vini colchici seminis f 5ij (8.0). 

Vinialbse q. s. f Siij (90.0).— M. 

S. — Tablespoonful (16.0) three times a day after meals. Shake well before 
using. 

The use of colchicum in such doses as to cause severe purgation or 
emesis is dangerous, and ought not to be resorted to. 

Colchicina, U. S., can be used successfully in gout in the dose of 
rio to to grain (0.0006-0.0012) three to five times a day. There are 
now on the market capsules or pearls of colchicine with oil of gaul- 
theria, each pearl containing from Tiro to eV grain (0.0006-0.001) of 
colchicine. They are very efficacious and are largely used. 

Poisoning. — The symptoms of poisoning by colchicum are nausea, 
griping, agony in the belly, purging followed by the passing of thick 
mucus, with great and increasing tenesmus, profuse salivation, col- 
lapse, and death from exhaustion and gastro-enteritis. Bloody purg- 
ing is almost never seen. The poisoning is one of the most painful, 
slow, and hopeless poisonings known, and a man taking as much as 
an ounce of the wine of the root or the seed is almost inevitably doomed 
to a terrible death. Tannic acid may be used as a partial chemical 
antidote, and the stomach washed out by the administration of emetics 
and the use of the stomach-pump. Opium is to be used to relieve the 
pain and irritation, and oils are to be given to soothe the inflamed 
mucous membrane. If collapse comes on, external heat and stimu- 
lants are to be used, and atropine may prove of service under these 
circumstances. 

Administration. — Colchicum ought never to be used in substance, but 
may be employed in the form of wine of the seed (Vinum Colchici 
Seminis) in the dose of 20 to 40 minims (1.3-2.6), although if a 
marked effect is required 60 minims (4.0) may be used. The extract 



238 DRUGS. 

(Extraction Colchici Cormi, U. S.) is given in the dose of J to 2 grains 
(0.03-0.12) and should contain 1.4 per cent, of colchicine. The 
fluidextract of the seed (Eluidextr actum Colchici Seminis, U. S.) 
should contain 0.4 Gm. of colchicine in each 100 mils., and is given 
in the dose of 2 to 4 minims (0.12-0.25). 

The tincture of the seed (Tinctura Colchici Seminis, U. S. and 
Tinctura Colchici, B. P.) is given in 15- to 60-minim (1.0-4.0) doses, 
and should contain 0.04 Gm. of colchicine in each 100 mils. The B. P. 
dose is 5-15 (0.3-1.0). The other B. P. preparations are Vinum 
Colchici, dose 10 to 30 minims (0.6-2.0), and Extraction Colchici, 
dose \ to 1 grain (0.015-0.06). 

Colchicine (Colchicine, U. S.) is given in pill in the dose of y^g- to 
sV grain (0.0006-0.0012). 

COLLODION. 

Collodium, U. S. and B. P., is a solution of gun-cotton or pyroxylon 
in alcohol and ether, and is a clear syrupy fluid, smelling strongly 
of ether. 

Therapeutics. — Collodion is used as an air-tight dressing for small 
wounds and abrasions and for rendering small dressings waterproof. 
A difficulty in its use consists in the contraction which fakes place as 
it dries, which draws and puckers the parts sufficiently to cause not 
only discomfort, but also acute pain. It should be applied with a 
camel's-hair brush. 

In boils, when they are beginning in a small pustule or papule with 
an inflamed zone, collodion painted over the spot, except at its very 
centre, will generally abort the suppuration. If the -boil has burst, 
this treatment is useless; but if it has not, the pus should not be liber- 
ated, but allowed to become inspissated. By this treatment and by 
the frequent application of a coat or two the local trouble eventually 
disappears. This rule applies only to certain cases, and if pain 'is 
caused by the retention of the pus, it must be evacuated with antiseptic 
precautions. In smallpox the flexible collodion may be used to pre- 
vent pitting. 

In gouty inflammations of the joints an application of collodion mixed 
with iodine, equal parts, will often diminish the pain, although at first 
the suffering may be increased by this treatment. 



Flexible Collodion, 

Flexible collodion (Collodium Flexile, U. S. and B. P.) is made by 
adding camphor 20 parts and castor oil 30 parts to 950 parts of ordi- 
nary collodion. It does not contract or become hard, and is generally 
to be preferred to ordinary collodion in the dressing of wounds. 



COLOCYXTH. 239 

Styptic Collodion. 

Styptic collodion (Collodium Stypticum) contains tannic acid, and 
has been employed to check small hemorrhages. It is seldom used, and 
its employment is an unsatisfactory way of controlling bleeding. 

Cantharidal Collodion. 

Cantharidal collodion (Collodium Cantharidatum, U. S.) has been 
referred to under the head of Cantharides. Collodium Vesicaus, B. P., 
is identical with this preparation, and is used for the same purpose. 

COLOCYNTH. 

Colocynthis, U. S., is the peeled dried fruit of Citrullus coloeynthis , a 
plant at present largely grown in all parts of the world. It contains 
an alkaloid, colocynthine, and a resin. Neither of these is used in 
medicine. Colocynth causes large watery evacuations, and may, 
in very large dose, produce fatal gastro-enteritis. It is official in the 
B. P. as Colocynthidis Pulpa. 

Therapeutics. — Colocynth is never used alone, but always in com- 
binations with other drugs of its class as a hydragogue cathartic. 

In cases of chronic dropsy and for the relief of serous effusions this 
drug is generally given in the form of the compound extract of colocynth 
(Extractum Colocynthidis Compositum, U. S. and B. P.), which con- 
tains 160 Gm. of extract of colocynth, 500 Gm. of purified aloes, 140 Gm. 
of the resin of scammony, 50 Gm. of cardamom, and 150 Gm. of soap. 
In the dose of 5 to 20 grains (0.3-1.3) this acts as a powerful watery 
purge useful in- dropsy. The extract (Extraction Colocynthidis, U. S.) 
is given with other drugs in the dose of 2 to 5 grains (0.12-0.3) as a 



purge. 



The following: is a useful form in which to administer it: 



n 



R — Extract! colocynthidis gr. xxx (2.0). 

Extracti belladonna? foliorum . . . gr. ij (0.1). 

Extracti nucis vomicse gr. ij (0.1).— M. 

Fiant pilulae Xo. x. 

S. — One each morning. 

Colocynth is one of the principal ingredients in compound cathartic 
pills (Piluloe Cathartic® Composite, U. S.). Each pill contains: com- 
pound extract of colocynth, 1^- grains (0.08); resin of jalap, J grain 
(0.02); and calomel, 1 grain (0.06); gamboge, % grain (0.015). This 
pill is not to be used constantly, as it eventually makes the bowels 
more constipated than before. 'The U. S. P. of"l900 also ordered a 
pill (Pilulce Catharticce Yegetabiles) which contained compound extract 
of colocynth, extract of hyoscyamus, resin of jalap, extract of leptandra, 
resin of podophyllum, and oil of peppermint. This is given in the 
dose of 1 to 2 pills and should not have been dropped. 

The preparations of the B. P, not official in the U. S. P. are: Pilula 



240 DRUGS. 

Colocynthidis Composita, composed of colocy nth-pulp, aloes, scam- 
mony, sulphate of potassium, and oil of cloves, dose 5 to 10 grains 
(0.3-0.6); Pilula Colocynthidis et Hyoscyami, dose 5 to 10 grains 
(0.3-0.6). 

CONDURANGO. 

Condurango is the bark of Condurango bianco, a tree of Colombia, 
South America. Martindale and Westcott state it is Gonolobus 
condurango. It was introduced into medicine in 1873 as a cure for 
gastric cancer-, and at one time had a favorable reputation. It is now 
known that, so far as the morbid growth is concerned, its action is 
valueless, but there is no doubt that it diminishes the severity of the 
symptoms in many cases by exercising a favorable effect on the gastric 
mucous membrane. It also tends to relieve the accompanying gastric 
catarrh through its action as a stomachic. 

The bark is never employed as the bark, but in the form of the fluid 
extract, dose 1 to 2 drachms (4.0-8.0), or the wine, dose \ to 1 ounce 
(16.0-30.0). Sometimes it is given in the form of a decoction made 
by adding 1 part of the bark to 8 parts of water, which is given in the 
dose of 1 tablespoonful (16.0) three times a day. Often it is advisable 
to add to the prescription a little hydrochloric acid to take the place of 
the natural acid of the stomach, which is usually lacking in such cases. 



CONIUM. 

Conium is the full-grown but unripe fruit of Conium maculatum. 
The plant grows in Europe and the United States, and contains 
a liquid alkaloid known as coniine. When kept for more than two years 
conium becomes unfit for use. 

Physiological Action. — Conium in full medicinal dose produces a 
feeling of relaxation and loss of muscular power, and if the dose be very 
large it causes giddiness, staggering gait, and disordered vision, with 
failure of the circulation. 

Nervous System. — Conium depresses the motor nerve plates, and, if 
the dose be extraordinarily large, the sensory nerves. Upon the spinal 
cord it exerts a slight depressing influence, but has no positive effect, 
while the fact that consciousness continues almost up to death shows 
that the intellectual portion of the cerebrum escapes its influence. 

Circulation. — The action of the drug upon the circulation is de- 
pressant. It causes at first a fall of arterial pressure; then, if the dose 
be large, a rise, due to the asphyxia caused by nervomuscular failure 
of the respiratory apparatus. Finally, a fall of pressure takes place. 

Respiration is depressed because of the paralytic influence of the 
drug on the respiratory centre and the nerve-trunks supplying the 
respiratory muscles. 

Therapeutics. — Conium holds an unimportant place in the drug-list 



CONVALLARIA. 



241 



Fig. 38. 




of to-day. It has little value except in spasms due to irritation of a 
nerve-trunk, when it may be of service. In spasms of cortical or spinal 
origin other drugs should be used, as it is evident that conium has 
no effect in quieting the central nervous protoplasm, but only pre- 
vents the impulses which are sent out from manifesting themselves 
in movements of the muscles. The powdered leaves or other prepara- 
tions may be smeared over poultices to relieve the pain of ulcers and 
cancers, and they certainly do good in such instances. 

Administration. — The dose of the alcoholic extract (Extractum 
Conii) is from i to 1 grain (0.03-0.06). The dose of the tincture 
(Tinctura Conii, B. P.) is § to 1 fluidrachm (2.0-4.0), B. P. Coniine is 
a liquid alkaloid which should never be used. The dose of the hydro- 
bromide of coniine is said by Helbing to be | to ^ grain (0.01-0.03). 
The preparation in the B. P. made 
from the leaves is Succus Conii, dose 
1 to 2 fluidrachms (4.0-8.0). Vapor 
Conii consists of the juice of hemlock 
(Succus Conii) J ounce (15.0), liquor 
potassse 1 drachm (4.0), and distilled 
water 1 ounce (30.0). Twenty minims 
(1.3) of this mixture are placed in hot 
water in an inhaler, and so employed 
for the relief of irritative coughs or 
spasmodic asthma. Unguentum Conii 
is official in the B. P., and is used in 
pruritus ani. 

It is to be remembered that the 
variability of the drug, so far as power 
is concerned, is very great — so great 
as to make it unreliable. For this 
reason a small dose should be given 
at first and the amount gradually 
increased. 

Poisoning. — A prominent symptom 
of poisoning by conium is dropping of 
the eyelids (ptosis), due to paralysis of 
the oculomotor nerves, and staggering 
and inability to walk. Its treatment 

consists in the use of strychnine as a respiratory and nervous stimu- 
lant, the employment of external heat, and the use of cardiac 
stimulants if the circulation fails. The stomach is to be emptied by 
emetics or the stomach-pump before the antidotes are used. 




A, conium acts as a depressant to 
the motor nerve-trunks. 



CONVALLARIA. 

Convallaria is derived from the rhizome and root-stalks of Con- 
vallaria ma j alls. It is .employed in medicine as a cardiac tonic to 
16 



242 DRUGS. 

fulfil the indications which direct us in the use of digitalis. While 
by no means so valuable a drug as foxglove, it sometimes acts better 
in an individual case than the older remedy. The heart is not greatly 
slowed by it, but the drug is particularly useful in cases of arrhythmia 
and "cardiac hurry." 

The dose of the fluidextract is from 4 to 8 minims (0.25-0.5) three 
times a day. The tincture (Tinctura Convallarioe) is given in the 
dose of 5 to 20 minims (0.3-1.3). Convallamarin is a glucoside of 
convallaria which has been used in the dose of \ grain (0.03) three times 
a day. Some clinicians think it ought to be given but once a day on 
account of the danger of cumulative action. 

COPAIBA. 

The Copaiba of the U. S. and B. P. is the balsam or the oleoresin 
of one or more South American species of Copaiba, and is a clear, trans- 
parent liquid of oily consistence, of a pale or brownish-yellow color 
and a peculiar odor. From it is distilled an oil which is of little value. 

As copaiba is an oleoresin, the term " oleoresin of copaiba" is often 
used to distinguish it from the oil. 

Therapeutics. — Copaiba is used for the purpose of stimulating the 
mucous membranes of the genito-urinary tract, particularly when they 
are depressed after a period of inflammation, as in the later stages of 
gonorrhoea. In cases suffering from chronic urethritis with anaemia 
and debility the following prescription is useful. (See also Methylene- 
blue.) 

1$ — Oleoresinae copaibse 5j (4.0). 

Oleoresinae cubebae TT1 xx (1.3). 

Ferri et ammonii citratis . . . . gr. xx (1.3). — M. 
Pone in capsulas No. x. 
S. — One t. i. d. after meals. 

Copaiba is employed in subacute and chronic bronchitis as a stimu- 
lant expectorant. In the treatment of subacute pyelitis, cystitis, and 
dysentery it is of value. In dropsy due to slow renal changes it is of 
service as a renal stimulant and diuretic. 

Administration. — Copaiba itself is given in the dose of 5 to 20 minims 
(0,3-1.3) in capsule or in emulsion. The oil of copaiba (Oleum 
Copaiba?, U. S. and B. P.) is given in capsule or emulsion, preferably 
in the former, in the dose of 10 to 20 minims (0.60-1.3) two to four 
times a day. Sometimes it is dropped on sugar and so administered. 
Massa Copaiba? is made by rubbing copaiba with magnesia, but this 
is a useless and clumsy way of using it in pill form. 

The drug is eliminated in the urine, and gives the test for albumin 
with nitric acid. 

Copaiba sometimes causes urticaria, which soon disappears on 
withdrawal of the drug. 



COPPER. 243 



COPPER. 



Cuprum is never used in the form of the metal itself, but chiefly as the 
sulphate (Cupri Sulphas, U. S. and B. P.), which appears in commerce 
as a blue, clear, somewhat efflorescent salt. It is soluble in 2.5 parts 
of cold water, and 0.5 part of boiling water, but it is not soluble 
in alcohol. 

Physiological Action. — Copper sulphate, when locally applied to a 
mucous membrane, acts as a powerful astringent, or on the surface of 
an ulcer as a mild and superficial caustic. When given in overdose by 
the stomach, it causes death by violent gastro-enteritis and exhaustion. 
Generally the symptoms do not appear for an hour, and consist in 
burning pain in the stomach, a coppery or metallic taste in the mouth, 
followed by vomiting of bluish liquids and glairy mucus. With the 
vomiting, purging comes on, the passages at first containing the con- 
tents of the intestine, and finally mucus and blood. Convulsions of an 
epileptiform character may be present, and constant and profuse saliva- 
tion is not infrequent. After death fatty degeneration of the liver and 
kidneys has been noted, and it is not uncommon for jaundice to ap- 
pear after the first twenty-four hours, if the patient survives so long. 
This jaundice is dependent upon changes in the blood. The treat- 
ment of the poisoning consists in the primary use of the chemical anti- 
dote, which is the yellow prussiate of potassium, and the administration 
of emollient or demulcent substances, such as sweet oil and white of 
eggs, followed instantly by emetics or the stomach-pump. If emesis 
and purgation are already active, emetics are of course contraindicated, 
counter-irritation is to be employed over the stomach and intestines 
in the shape of a mustard plaster of moderate strength, and opium given 
to allay irritation and relieve pain. 

Chronic copper poisoning is almost never seen, and, although the 
metal is widely used for coloring canned green vegetables, it seems to be 
harmless when ingested in such small amounts. 

Therapeutics. — Sulphate of copper in the dose of 5 to 7 grains (0.3-0.46 
may be used as a rapidly acting emetic which acts only upon the stomach, 
but not upon the vomiting centre. As it is irritant, the emetic dose 
ought not to be repeated, but if emesis does not occur the sulphate of 
zinc or mustard should be used to empty the stomach. Indeed, it 
may be said of sulphate of copper that it should never be given as an 
emetic if any other emetic can be found. Thornton has proved in 
the Laboratory of Experimental Therapeutics of the Jefferson Medical 
College that an antidotal dose of copper sulphate given to a dog poisoned 
with phosphorus may produce death before the phosphorus can cause 
a lethal result. The drug is, therefore, a theoretical, but not a practical 
antidote to phosphorus. In pill form it is sometimes given in diarrhoeas 
depending upon ulceration of the bowels. The dose should be J- to 1 
grain (0.015-0.06) combined with opium. 

In amoebic dysentery sulphate of copper (2 grains to the pint) , which 



244 DRUGS. 

destroys the amcebse, may be employed for irrigation of the colon in 
hot solutions (105°-110° F.) once or twice a day. (See Enteroclysis 
for method.) 

In some states of the body, particularly in skin diseases of the dry 
type and in individuals with tubercular tendencies, copper seems to 
act like arsenic, and may be used in doses of y^ grain (0.006) or less 
three times a day when arsenic is not well borne. In small doses it 
is said to be a direct stimulant to the tissues, and to increase the 
firmness of the flesh and strength of the normal man. Strong 
claims for copper as a remedy for anosmia have been advanced, 
particularly if it is employed as the arsenite of copper, when the con- 
joint action of the arsenic and copper produces a good effect. 

Sulphate of copper in the proportion of 1 to 50,000,000 or 1 to 
5,000,000 has been proved to be exceedingly valuable for the purpose 
of purifying water potable except for the growth of algae, which make 
it foul. In these proportions it also destroys the typhoid bacillus, and 
it should be placed in all springs, ponds, or reservoirs which may be 
contaminated by these germs. In these quantities it is harmless to 
man and animals. 

Locally applied, sulphate of copper is useful, in the solid form or in 
powder, in the treatment of indolent ulcers. In chronic conjunctivitis 
or in cases of tinea tarsi — that is, tinea on the margin of the eyelids — a 
crystal of the sulphate may be drawn over the diseased spot; or a 
solution of 1 to 3 grains (0.06-0.20) to the ounce (30.0) of water may be 
dropped into the eye in subacute conjunctivitis. 

In relaxed sore throat, as a gargle, in the strength of 4 grains (0.25) to 
the ounce (30.0), it is often of service. 



CORPUS LUTEUM. 

The yellowish body found at the site of a recently ruptured Graafian 
follicle in the ovary of a non-pregnant animal, usually the sow, has 
been introduced into medicine, in desiccated form, for the purpose of 
relieving symptoms associated with menstrual disturbances. It 
gives excellent results in relieving the nervous disturbances which are 
manifested during the artificial menopause due to removal of the 
ovaries. This substance also seems to do good in amenorrhea and 
scanty menstruation, particularly that occurring in overfat young 
women and in some cases of dysmenorrhea and menstrual migraine. 
It has also given good results in the vomiting of early pregnancy, but 
if the blood-pressure falls under its use more than 15 points its 
administration should be stopped. 

The dose usually given is 5 to 20 grains (0.3-1 3) three times a day 
after meals, but, if need be, a far larger dose may be used, as it seems 
to be innocuous. It may be given in capsules or tablet form, or 
intramuscularly from ampoules containing 15 minims (1.0) of soluble 



CREOSOTE 245 

extract, equivalent to 2.5 grains of the desiccated substance, once a 
day. The needle or syringe should be sterilized by boiling, as phenol 
impairs the drug. 

COTARNINE. 

Cotarninze Hydrochloric! um, U. S., is prepared from narcotine, one 
of the alkaloids of opium, but its physiological effect is closely allied 
to that of hydrastinine, derived from hydrastis. In the form of 
cotarnine hydrochlorate it has been placed on the market as " Stypti- 
cin," and this is used as a remedy for oozing hemorrhages, such as 
menorrhagia and metrorrhagia, and as a local application in epistaxis. 
It may be given in the dose of from \ to 4 grains (0.03-0.25) three 
times a day in pill, tablet, or elixir, or in capsule, or by the hypodermic 
syringe in the dose of 1 to 2 grains (0.06-0.12). 

CREOLIN. 

Creolin is a liquid cresol, a coal-tar product, possessing marked 
antiseptic but comparatively slight poisonous properties. It is a 
dark-brown fluid derived from soft coal, and is of the consistence 
of syrup. "When added to water it forms a white cloud and mixes 
thoroughly, forming an emulsion up to 12 per cent, of the drug. 

Therapeutics. — Creolin is used as an antiseptic in the lying-in state, 
as a wash for the hands and for vaginal irrigation. It cannot be used 
as a solution in which to place instruments, as the mixture with water 
is so opaque as to prevent their being seen when lying at the bottom of 
the dish. When used as a vaginal douche it should be employed in the 
strength of 2 per cent. One of its properties which is of value is that it 
forms a slippery coating over the maternal parts during parturition. 
In the treatment of cystitis in the female, Parvin highly recommended 
it as a vesical wash in the strength of a 1 per cent, solution, or, after the 
bladder becomes accustomed to its use, in a 2 per cent, solution. 
According to Kretzschmar and others, a solution of 1 to 500, used with 
a syringe, is useful in otorrhea, 1 to 100 in nasal idcers, and 1 to 1000 as 
a nasal douche in rhinitis when there is much discharge with the forma- 
tion of crusts. Creolin has also been used as an injection in the pro- 
portion of 5 parts in 1000 of water for dysentery and colitis with success. 

A useful ointment for fetid sweating of the feet is— 

I*. Creolin foj (4.0). 

Hydrargyri ammoniati gr. x (0.65). 

Acidi salioylici gr. x (0.65). 

Petrolati molli 5j (30.0).— M. 

CREOSOTE. 

Creosote (Creosotum, U. S. and B. P.) is a mixture of phenols and 
phenol derivatives, chiefly guaiacol and creosol, obtained during the 



246 



DRUGS. 



Fig. 39. 



distillation of wood-tar, preferably of that derived from the beech, 
Fagus silvatica, Linne, or Fagus ferruginea, Alton (Fam. Fagaceoe). 

It occurs as an almost colorless, yellowish (not pinkish), highly refrac- 
tive, oily liquid, having a penetrating, smoky odor, and a burning, 
caustic taste. It should not become brown in color on exposure to 
light. Its specific gravity should not be below 1.073 at 25° C. 
(77° F.). 

Its solution in about 140 parts of water at 25° C. (77° F.) is not 
perfectly clear. With 120 parts of hot water it forms a clear liquid, 
which, on cooling, becomes turbid from the separation of minute oily 
drops (distinction from, and absence of, both phenol and so-called 
"coal-tar creosote"). Much of that sold is derived from coal-tar, and 
is far less useful. Chemically, creosote is almost identical with phenol; 
clinically, it is very different. Its physiological action is almost 
identical with that of phenol, and in poisoning by creosote the 
same antidotes as are employed in phenol poisoning — namely, soluble 
sulphates — should be used, as has been proved in experiments by the 
author. Creosote contains 60 per cent, of guaiacol and 40 of creosol, 
not cresol. Guaiacol is sometimes used in place of creosote in the 
dose of 1 to 2 minims (0.05-0.10). (See Guaiacol.) Creosote is a 
powerful antiseptic. 

According to the studies of Imbert, creosote is eliminated chiefly by 
the kidneys in the form of guaiacol sulphate and creosol sulphate of 

potassium. Elimination is not rapid, 
for this investigator did not find it com- 
pleted for about twenty-eight hours. 
A small amount of the drug is elimi- 
nated by the lungs. 

Therapeutics.— During the past few 
years creosote has been largely pre- 
scribed in pulmonary tuberculosis and 
chronic bronchitis, and some of the 
results reached by its use have un- 
doubtedly been of value in these affec- 
tions. (See article on Tuberculosis.) 
It has also been inhaled from sponges 
with great relief, and even has been 
injected into the lungs byway of the 
trachea or through the chest- wall. In 
the treatment of chronic bronchitis 
creosote may be placed in boiling 
water and inhaled in the steam. 
Under these circumstances it lessens 
the fetor of the breath, and this 
method often gives more rapid relief 
than any other measure in the treat- 
ment of ordinary subacute inflamma- 
tion of the bronchi. (See Inhalations.) The beginning dose when the 
drug is given internally is 2 to 5 minims (0.1-0.30). 




Yeo's inhaler, made of perforated zinc, 
bound on the edges with chamois skin, and 
supplied with elastic loops to go back of the 
ears. On a sponge placed in front of the 
.inhaler is dropped the medicament to be 
inhaled. 



CREOSOTE. 247 

It is useless to attempt to cure pulmonary tuberculosis by the ad- 
ministration of creosote, and its chief value in the disease depends upon 
its action as an expectorant affectine favorably the profuse bronchial 
secretion associated so often with the involvement of the lung tissues 
by the tubercular process. Creosote does good, indirectly, by relieving 
this complication ; but it is apt to disorder the digestion. It ought not 
to be employed in every case, since its value in relieving the bronchial 
disorder is far outweighed by the disturbance of digestion in many 
instances. If fever or haemoptysis is present, the use of creosote is 
contraindicated. When it is desired to relieve profuse mucopurulent 
expectoration creosote may be given in capsule or as follows: 

B— Creosoti (beechwood) £5iij (12.0). 

Tincture? gentianae composite . . . f oj (30.0). 

Spiritus viiii rectificati f.fvii (240.0). 

Viiii Xerici Oij (960.0).— M. 

S. — A tablespoonful in a wineglassful (16.0 : 60.0) of water three times a day. 

In other cases the creosote may be dropped into half a glassful of milk 
and taken in this three times a day. Often as ouch as a drachm a day 
can be given by gradually producing tolerance through ascending 
doses; and it is worthy of note that in most instances large doses are 
required if satisfactory results are to be obtained. (See article on 
Tuberculosis, Part IV.) 

In the advanced stages of phthisis inhalations of the drug often 
decrease the cough, relieve the laryngeal dryness, and promote expec- 
toration. When creosote is used hypodermically in phthisis, it may 
be given in the following formula: 

3— Creosoti fSij (8.0). 

Olei amygdalae expressi f oij (8.0). — M. 

S. — 10 minims (0.60) to be injected deeply into the tissues below the scapula. 

This method is not to be employed except in rare cases. Indeed the 
author has yet to see a case in which its use seemed wise. 

In the treatment of subacute laryngitis a fine spray of 1 to 2 minims 
(0.06-0.12) of creosote, 4 grains (0.25) of menthol, and 1 ounce (30.0) 
of albolene, is of service used several times a day; or a mixture com- 
posed of creosote 10 minims (0.60), chloroform spirit 10 minims (0.60), 
and alcohol 20 minims (1.3), may be placed on the sponge of an inhaler 
and inhaled. It is also claimed that wetting cloths with creosote and 
hanging them in the air of a nursery are of great value in whooping- 
cough. (For methods, see Inhalations, Part III.) 

Sometimes creosote is given by enema in pancreatized cod-liver oil to 
children with pulmonary or peritoneal tuberculosis, in the dose of from 
5 to 15 minims (0.3-1.0). 

Creosote is a valuable remedy in cases of indigestion with fermenta- 
tive changes in the gastric contents when these arise Sm the deficient 
digestion of meats or the use of sweets, given in the dose of \ to 2 
minims (0.025-0.1) after meals, preferably in tablet or capsule. Applied 
on a pledget of cotton to the cavity of a carious tooth, creosote often 



248 DRUGS. 

relieves toothache by virtue of its anaesthetic influence over peripheral 
sensory nerves. 

While ordinary medicinal doses of creosote rarely cause disagreeable 
symptoms except some disorder of the stomach or bowels when it is 
given in full doses, the physician who is ordering large amounts should 
be always on the lookout for toxic symptoms. These consist in vertigo, 
headache, and a tendency to stupor, and the urine may become smoky 
in appearance, as in phenol poisoning. If any of these signs of over- 
dosing appear, the drug must be reduced in dose or stopped altogether. 

The preparations of creosote are Aqua Creosoti, U. S., which is given 
in the dose of 1 to 3 fluidrachms (4.0-12.0); Mistura Creosoti, B. P., 
dose J to 1 fluidounce (15.0-30.0); Unguentum Creosoti, B. P., for 
local application. 

CREOSOTE CARBONATE. 

Creosote carbonas, sometimes called "Cresotal," is a combination 
of creosote with carbonic acid. Over 90 per cent, of creosote carbonate 
is said to be creosote. It is a thick, oily fluid of an amber color, with 
but little taste or odor, and is insoluble in water, dilute alcohol, and 
glycerin, but is soluble in 95 per cent, alcohol, in ether, chloroform, and 
in cod-liver and olive oils. It is said to be less irritating to the stomach 
than creosote. The drug is dissolved and absorbed chiefly in the intes- 
tine. The dose of creosote carbonate varies from 15 to 30 grains (1.0- 
2.0) twice or thrice a day after meals. It is used as an expectorant in 
pulmonary tuberculosis and as an intestinal antiseptic. It is best given 
in capsule. (See also Guaiacol, Carbonate of ) It has been claimed 
that this drug possesses great virtue in cases of croupous pneumonia, 
but careful clinical research has failed to show that this is true. 

CROTON CHLORAL. 

Croton chloral, or Butyl Chloral Hydras, B. P., has a physiological 
action- closely allied to that of chloral itself, but it possesses more 
analgesic power and is much less depressant to the heart and circu- 
lation. The dose for the production of sleep is the same as chloral, 
5 to 20 grains (0.3-1.3) in syrup. 

Therapeutics. — Croton chloral is preferable to chloral in sleepless- 
ness due to pain. 

In facial neuralgia and migraine it is exceedingly efficacious, par- 
ticularly if the fifth nerve be involved. In headaches due to eye-strain, 
and in those associated with sick stomach, but not due to gastric indi- 
gestion or nervous debility, croton chloral is of service. Curiously 
enough, it is valueless in toothache, but is useful in the neuralgia due 
to decayed teeth. 

Administration. — Croton chloral should be used in pill form in the 
dose of 3 to 5 grains (0.2-0.3) every two hours until the pain is relieved or 
sleep comes on, or it may be given in solution or syrup of acacia and 
water, or water and glycerin. It has been used in as large a dose as 



CUBEBS. 249 

60 grains (4.0), but 20 to 30 grains (1.3-2.0) ought to be the maximum 
dose as a general rule. 

CROTON OIL. 

Croton oil (Oleum Tiglii, U. S.; Oleum Crotonis, B. P.) is an exceed- 
ingly irritant oil derived from Croton tiglium, a small tree of India. 
The oil is pale or brownish yellow in hue and of a complex character. 
Applied to the skin for any length of time, it is an intense irritant, 
producing blisters or pustules.. 1 minim (0.06), placed on the tongue 
with 5 minims (0.30) of sweet oil, acts as a violent watery purge, and, 
owing to the smallness of its dose, it is frequently employed to revulse 
the unconscious, as in cerebral congestion. In delirium it is used for 
the same purpose, and may be given to maniacs who are suffering from 
an attack of cerebral congestion or obstinate constipation, owing to 
the smallness of its dose and rapidity of action. The dose is 1 minim 
(0.06) placed on the tongue with sweet oil or given in emulsion or in 
pill. It ought never to be used when there is any irritation of the 
stomach or bowels. As a counter-irritant it is sometimes applied over 
a tender nerve or to the chest in the treatment of bronchitis, in the pro- 
portion of half-and-half with sweet oil. Thus applied, it may be 
absorbed and cause purging. The treatment of poisoning by croton 
oil is identical with that of gastro-enteritis. (See Gastro-enteritis.) 
Linimentum Crotonis is a preparation of the B. P. which is employed 
as a counter-irritant liniment for sprains and in muscular rheu- 
matism. 

CUBEBS. 

Cubebs (Cubeba, U. S., and Cubeba Fructus, B. P.) are the unripe 
fruit of Piper cubeba, a plant of Java. They are wrinkled or rough 
black bodies about the size of small peas, and have an aromatic, 
pungent taste. They contain a volatile oil, cubebic acid, and cubebin. 
The drug should not be kept in powdered form, as it loses its powers, 
but should be powdered as needed. Overdoses of cubebs cause gastro- 
intestinal and genito-urinary inflammation. 

Therapeutics. — Cubebs are used in the advanced stages of gonor- 
rhoea when a tendency to a chronic discharge is present. Some sur- 
geons have used them in the early stages as an abortive treatment, but 
this is a bad practice. In cold in the head the powdered berries may 
be snuffed up the nostril when the stage of secretion is well estab- 
lished. They ought not to be used before this stage. In the treatment 
of chronic or subacute bronchitis the oleoresin of cubebs is very useful in 
some cases (see Bronchitis), and in the form of cubeb cigarettes the 
drug is much used as a remedy for hoarseness due to subacute laryngitis. 

Administration. — Cubebs may be given in powder in the dose of 
10 to 60 grains (0.60-4.0), as the fluidextract, 10 to 30 minims (0.60- 
2,0), and in the form of the tincture (Tinctura Cubeba, B. P.) in the 
dose of 10 minims to \ ounce (0.60-16.0), \ to 1 fluidrachm (2.0-4.0), 
B. P. 



250 DRUGS. 

The dose of the oleoresin (Oleoresina Cubebce, U. S.) is 2 to 20 minims 
(0.1-1.3) three times a day, and it may be given in capsule or emulsion. 
The troches of cubebs (Trochisci Cabebce, U. S.) are used for the relief 
of pharyngitis of a chronic type. The dose of the oil (Oleum Cubebce, 
U. S. and B. P.) is 5 to 20 minims (0.3-1.3). 

cusso. 

Cusso, sometimes called Kousso, is the dried panicles of the pistil- 
late flowers of Hagenia abyssinica. In the U. S. P. of 1880 it was called 
Brayera. It contains a volatile oil, tannic acid, and koosin or tamiin. 
The drug is used to expel the tape-worm, and is most valuable as a 
vermifuge, also possessing the advantage of safety. It should be 
used in an infusion (Infusum Brayerce) in the dose of § ounce (16.0) 
of the powdered flowers to a pint (480 mils.) of water, and be taken in 
the morning on an empty stomach. (See Worms.) Koosin may 
be used in the dose of 20 to 40 grains (1.3-2.6) in capsule. The 
fluidextract (Fluidextractum Cusso) is given in the dose of \ ounce 
(16.0). It has been claimed that the drug is apt to cause abortion in 
pregnant women, but this is not known to be a fact. 

DIASTASE. 

The word diastase (Diastasum, U. S.) is applied to substances 
found in certain of the digestive juices of the animal body and present 
in processes connected with the fermentation of grain, as, for example, 
in the manufacture of alcoholic beverages. Whatever diastase may 
be, we recognize that it belongs to the same class of enzymes as pepsin 
and pancreatin, and that it has the power of converting starch into 
sugar. Many preparations of malt contain some diastatic power, 
but there is only one preparation of diastase which possesses no 
other property save that of aiding the digestion of the starches — 
namely, one prepared originally by a Japanese investigator, Taka- 
mine, and called from his name "Taka-diastase." It is used to 
relieve cases of indigestion of starchy foods in the dose of 2 to 5 grains 
after meals, in tablet or capsule or in a solution, and is a most 
efficient remedy. 

A useful formula is as follows: 

1$ — Taka-diastase . gr. xlv (3.0). 

Pancreatini . gr. xlv (3.0). 

Extracti nucis vomicae gr. iv (0.25). — M. 

Pone in capsulas No. xx. 
S. — One capsule with meals. 

Often a little capsicum may be added to this prescription, in the 
treatment of atonic dyspepsia, with advantage. 

In the artificial feeding of infants it is often necessary to largely 
dilute the cows' milk and equally needful to maintain its nutritional 
value. This can be accomplished by adding barley gruel which has 



DIGITALIS. 251 

been strained and then largely converted into dextrin or maltose by 
adding taka-diastase to it while it is still warm, but not boiling hot. 
The diastase can be destroyed after its effects are induced by bringing 
the gruel to the boiling-point for a few moments. 

Taka-diastase, in the dose of 5 to 10 grains (0.3-0.6) three times a 
day, sometimes decreases the loss of sugar, and more frequently greatly 
diminishes polyuria in diabetes mellitus. 

DIGITALIS. 

Digitalis, U. S., is the dried leaves of Digitalis purpurea, Linne, or 
Foxglove, collected from plants of the second year's growth, at the com- 
mencement of flowering. The leaves are official in the B. P. as Digitalis 
Folia. It contains a number of substances, no single one of which 
acts as do preparations of the crude drug. In other words, all these 
compounds must act together to produce therapeutic effects similar 
to those obtained when digitalis leaves are given. Among the sub- 
stances so far isolated from digitalis by chemists may be named digi- 
talin, digitalein, digitoxin, digitin, and digitonin. Several of these 
are probably compounds of the others. Digitalin, so-called, occurs in 
two forms, amorphous and crystalline. The crystalline digitalin 
(Xativelle, French) is largely digitoxin, while the amorphous form is 
composed of digitonin, digitalein, and digitalin. German digitalin is 
about 50 per cent, digitonin and 6 per cent, true digitalin. Digitoxin 
and pure digitalin are the two most active principles yet found. None 
of these substances should be used in medicine to take the place of 
digitalis, but digitalin and digitoxin may be used as a heart stimulant. 
(See Administration.) 

In the early part of this volume the necessity of employing reliable 
drugs was pointed out. In the instance of digitalis this is particularly 
important, because the cases in which it is used are often serious, and 
because digitalis varies greatly in strength. As a rule, the wild digi- 
talis is stronger than the cultivated, and the English or German digitalis 
is better than the American. The preparations of digitalis should 
therefore be obtained from a reputable manufacturing pharmacist 
after they have been physiologically tested. 

Physiological Action. — Digitalis is apt to irritate mucous membranes 
which are already slightly out of order, and for this reason should not 
be given by the mouth in large doses in cases of gastritis and allied 
states if it can be avoided. 

Nervous System. — The action of digitalis upon the nervous system 
is only manifested when poisonous doses are used. Small toxic doses 
decrease reflex activity by stimulating Setschenow's reflex inhibitory 
centres in the medulla, and finally by depressing the spinal cord. 
Convulsions are sometimes seen as a result of the action of decom- 
position products of digitalis— namely, toxiresin and digitalresin. 
Finally, the motor nerve-trunks themselves are depressed and the 
muscles are paralyzed. Xone of these effects are seen in man. 



252 



DRUGS. 



Circulation. — Upon the circulatory system digitalis exerts its chief 
influence. In moderate or medicinal amounts it increases the pulse- 
force and arterial pressure, slows the pulse, and increases the size of 
the pulse-wave. The increase of pulse-force is due to a stimulating 
influence exercised upon the muscular fibers of the heart. Gottlieb 
and Magnus have shown this to result in the doing of two and one-half 
times the normal amount of work. 

Not only does digitalis stimulate the ventricular wall to greater effort, 
and restore its tonicity when this is impaired, but the prolongation of 
the period of diastole permits the heart to regain its irritability, con- 
tractility, and also the conductivity of its muscular fibers. The longer 
the diastole, therefore (diastole being the period of resuscitation), the 
greater the power of the next contraction. (See below.) 



Fig. 40. 




A, digitalis stimulates the heart: B, stimulates the vagus centres; C, stimulates the peripheral 
ends of ^he vagi; D, stimulates the vasomotor centre; E, stimulates the walls of the blood- 



The rise of arterial pressure is caused by the increase in pulse-force 
and pulse-volume, and by stimulation of the vasomotor centre and the 
muscular coats of the bloodvessels, whereby constriction occurs in the 
walls of the arteries and arterioles. Some recent investigations on 
human beings by means of the sphygmomanometer seem to indicate 



DIGITALIS. 



253 



that a rise in pressure often fails to take place, but while this may be 
true in cases in which the pressure is normal or above normal it is not 
true in all cases of low pressure due to ruptured compensation in 
valvular disease. At times the drug may in a case of impaired circu- 
lation lower the pressure, since by improving the circulation in the 
medulla and in the lungs it may cause an increased elimination of C0 2 , 
which in amounts which are not very excessive may raise pressure 
and so increase the work of the left side of the heart. 



Fig. 41. 



i 


II 


in 

(iyf 


AnJ^\ 


\0\l^\ 


l/V ^ v y 







Showing the effect of digitalis on the circulation. (After Schmiedeberg.) I. Before digitalis 
was used: blood-pressure 86, pulse 21 in ten seconds. II. After the use of digitalis: blood- 
pressure 150, pulse 22 in ten seconds. III. After another dose: blood-pressure 164, pulse 20. 
IV. Alter another dose: blood-pressure 210, pulse 40. 

The slow pulse is produced by stimulation of the pneumogastric 
centre and the peripheral ends of the vagus nerves. The increase in 
the volume of the pulse is due to a more complete contraction than 
normal and to the influence on the vagi; for, the pneumogastric nerves 
being stimulated, the diastole of the heart is more full and complete and 
occupies a greater length of time. The result of this delay is that the 
ventricles become thoroughly distended, and on contracting drive out a 
much larger wave of blood through the aorta than is normally sent out 
(Figs. 40 and 41). This is important to remember when using the 
drug in heart disease and other states. 

While it is not known that the vagi are the trophic nerves of the 
heart, there is a large amount of evidence in favor of such a view, and 
it has long been thought that digitalis was not only a heart stimulant, 
but a remedy that increased the growth of its muscular tissue as well. 



254 DRUGS. 

If the trophic nerves of the heart are stimulated by digitalis, it becomes 
evident that it is a doubly useful remedy. 1 (See article on Heart Dis- 
ease, in Part IV. of this volume, for a further explanation of the 
influence of digitalis in improving the nutrition of the heart muscle.) 

When full medicinal doses of digitalis are frequently repeated, or when 
poisonous doses are ingested, the action of the heart may become exceed- 
ingly irregular. (See Poisoning.) This irregularity may be explained 
as follows: In health the contraction-wave in the heart arises in the 
sino-auricular node, and passes by way of the muscular fibres of the 
bundle of His over the auricles to the auriculo-ventricular junction, 
where it is transmitted by this bundle of His to the ventricles in reg- 
ular sequence. If any cause interferes with the normal transmission 
of the contraction-wave from the auricles to the ventricles, incoordi- 
nation between these parts of the heart develops. If a regular sino- 
auricular impulse reaches the ventricle, a normal heart-beat occurs, 
but if it fails to reach the ventricle, this part of the heart does not 
contract, or, if it does contract, it originates its own contraction im- 
pulse, and, therefore, the ventricular contraction becomes entirely inde- 
pendent of auricular contraction, both in its origin and in its time, with 
the result that the ventricle may contract only half the number of 
times per minute that the auricle contracts. 

A toxic amount of digitalis may produce this condition in the fol- 
lowing manner: Through its influence on the vagi, it distinctly inter- 
feres with the passage of the contraction-wave over the bundle of His, 
although digitalis does not seem to directly effect this bundle. As a 
result, some or all of the contraction-waves arising at the sino-auricular 
node fail to reach the ventricle and incoordination results. Second, 
the digitalis stimulates the ventricle to increased activity, and this aids 
in the production of extra systoles when the ventricles beat independ- 
ently of the auricles. 2 Auscultation of the heart will reveal many 
beats, some of which are evidently normal, except that they may be 
unduly deliberate. Other beats are abortive, with the result that the 
heart-sounds seem jumbled and irregular as to rhythm and force. 
The radial pulse may be much less frequent than the apex-beat, 
because the extra systoles may not have sufficient blood and force to 
produce a pulse at the wrist. The development of extra systoles or 
of dropped beats when digitalis is being freely used should cause the 
physician to stop its administration at once. (See Heart Disease, 
and especially Mitral Stenosis.) Sometimes a distinct jugular pulse 
is readily observed which may be synchronous with ventricular con- 
traction, because the right ventricle forces the blood backward through 

1 In an original study by the author he found that when digitalis is given continuously 
for a long period of time there results cardiac hypertrophy independently of any valvular 
lesion. See Therapeutic Gazette, December, 1897. 

2 In some of the earlier editions of this book I have ascribed the irregular action of the 
heart under digitalis to a struggle between its vagus effect and its muscle effect. Recently 
developed knowledge as to His' bundle, as just given, seems to confirm this earlier view, 
now expressed in different terms. 



DIGITALIS. 255 

the right auricle. This irregular pulse, caused by an excess of digi- 
talis, is sometimes replaced by an exceedingly rapid pulse, which is 
shuttle-like in character, and, whether the pulse be irregular or rapid, 
the arterial pressure may be, at this time, low, owing, first, to the 
imperfect action of the heart, and, second, to a depression of the vaso- 
motor centres and the muscular coats of the bloodvessels. The rapid 
pulse, when it occurs, is probably due to a depression of the peripheral 
ends of the vagus nerves. 

If a patient who has taken a poisonous dose be suddenly placed in 
an upright posture, death may ensue, owing to the disturbance of the 
contraction-wave in the heart produced by the erect posture. Under 
these circumstances the heart beats so abortively that the circulation 
fails, the condition produced being like that of complete heart-block 
arising from a lesion in His' bundle, as in Stokes-Adams Disease. 

Respiration. — Digitalis has almost no effect on this function unless 
the amount be poisonous, when respiration is slowed. 

Temperature. — Upon the normal bodily temperature digitalis has 
little or no effect in medicinal dose. In poisonous dose it lowers tem- 
perature. In fever the drug seems to cause a slight fall with some con- 
stancy, but it can rarely be used for any antipyretic influence. High 
temperatures prevent digitalis from slowing the pulse, because, as proved 
by Brunton and Cash, fever depresses the vagus centres in the medulla, 
and also in all probability, when the temperature is very high, the 
peripheral ends of the vagus. This is an important point to be remem- 
bered in the therapeutic use of this drug. 

Kidneys, Tissue-waste, and Elimination. — Digitalis has almost 
no effect upon the kidney structure itself, and does not to any extent 
stimulate the renal epithelium. The cause of the increased urinary 
flow produced by digitalis in cases of cardiac dropsy depends upon the 
removal of congestion of the kidneys and the increased arterial pressure 
and improved circulation brought about by the drug. 

It is important to remember that digitalis, if given in cVerdose, may 
cause a spasm of the bloodvessels of the kidney, and so cause sup- 
pression of urine. This is usually accompanied by the development of 
cumulative effects. 

Upon tissue-waste digitalis seems to have little effect, but there is 
still some discrepancy in the reports as to the amount of urea excreted 
under its use, some investigators saying it is increased, others that it 
is diminished. 

It is not known how the drug is eliminated, as chemists have never 
been able to detect it in the urine. It is probably oxidized in the body. 

Poisoning. — The slow, full pulse followed by the hobbling, dicrotic, 
shuttle-like pulse-beats, and the tumultuous cardiac beat, afford a com- 
bination of symptoms characteristic of the overaction of digitalis. 
The pulse may be full and slow when the patient is recumbent, but at 
once becomes irregular on his sitting up. 

As the poisoning progresses vomiting may come on, exophthalmos 



256 DRUGS. 

occurs, and a peculiar blue pearliness of the sclerotic is seen. Con- 
sciousness is generally preserved nearly to the last. Death from digitalis- 
poisoning may not take place for days or may occur in two hours or 
even less. Headache is often a severe symptom. 

Treatment of Poisoning. — Tannic acid is to be given as a chemi- 
cal antidote; emetics and the stomach-pump are to be used, the former 
only when the drug has not been absorbed, for if the heart is much 
affected emetics are dangerous. External heat is to be applied, particu- 
larly about the abdomen. The maintenance of a horizontal position must 
be insisted upon for several days after active symptoms have subsided, 
for sudden death on sitting up has occurred. The use of tincture of 
aconite, as the physiological antidote, may be resorted to. 

Therapeutics. — Much misunderstanding concerning the action of 
digitalis has arisen, and, while some call it a circulatory stimulant, 
others think it a circulatory depressant. The first class base theii 
belief on the signs of increased arterial pressure and cardiac power, 
the others on the fact that it slows and steadies an irritable, rapidly 
acting heart but overlook the other signs. Digitalis is a cardiac 
stimulant and not a depressant. The quieting of irritability by it is 
the quietness produced by the drink of whisky or coffee taien by 
the pugilist before he enters the ring, to steady his nerves and make 
him firm. If digitalis is used to decrease arterial tension, its dose 
must be dangerously large. (See Physiological Action.) 

Digitalis is of value in nearly all cases of cardiac disease where the 
condition is one in which the heart fails to do its proper amount of 
work unless the failure is due to myocardial degeneration. If simple 
hypertrophy or excessive compensatory hypertrophy exists, it is harmful. 
It is of less value in aortic regurgitation than in any other lesion, because 
the prolongation of diastole allows greater opportunity for the blood 
to fall back into the ventricle, although in the second stage of this 
lesion, when the mitral orifice and valve are beginning to be affected, 
it is often very useful. In some instances of mitral regurgitation the 
drug does harm by overdistending the auricle through ventricular 
stimulation, which results in an increase in the regurgitant flow, and 
we can never tell before trying it which cases will be so affected. (See 
Heart Disease. 1 ) In cases where the heart is irritable, palpitation 
present, and indigestion not the cause of the trouble, digitalis is of 
service. It is also useful in cardiac dilatation and asthenia, and in that 
condition which Da Costa called a "tired heart." 

In the second stage of pneumonia if the heart is laboring and unable 
to do its work properly, digitalis is often invaluable (see Pneumonia). 
In congestion of the lungs in the typhoid state it will drive out the blood 
from the part congested and relieve stasis unless the temperature is so 
high that it cannot act or the heart muscle is degenerated. 

In cardiac weakness from collapse, injury, poisoning, or shock digi- 

1 It is absolutely necessary for the student to turn to the article on Heart Disease, and 
to read it carefully, in order to understand the action of digitalis in disease. 



DIGITALIS. 257 

talis is of service, particularly in aconite-poisoning, in which it is the 
physiological antidote. Owing to its tardy action it should, however, 
be preceded by ammonia and strychnine where the need is pressing. 
In muscarine poisoning digitalis and atropine are the antidotes. 

As a diuretic digitalis is most useful when the kidneys are congested 
and the circulation is sluggish from cardiac feebleness. When the renal 
structure is diseased, other drugs should take its place, or it should be 
combined with more active renal remedies, such as squill or caffeine, 
or with compound spirit of juniper in very chronic cases of kidney 
trouble. 

As digitals acts very slowly, but maintains its effect for a long time, 
it may be given only once a day after its effects have been obtained, 
for the purpose of continuing its influence. 

Often when the patient has by error received too much of the drug 
the finger can scarcely note any pulse at the wrist, yet the ear when 
placed over the heart finds it to be beating forcibly but abortively. It 
is important that the weak pulse at the wrist be not taken as the only 
guide as to the state of the patient for this very reason, and the phy- 
sician should always auscult the prsecordium before reaching an opinion 
as to the action of digitalis. (See Physiological Action.) 

Untoward Effects. — Digitalis sometimes causes nausea and indigestion 
by irritating the stomach. In children it is likely to produce marked 
irregularity of the pulse. "When given in full doses, the patient should 
always remain in bed and not be allowed to sit up suddenly, as syncope 
may occur. It is particularly important that this rule be enforced if the 
patient desires to empty the bladder, for cases are on record in which 
a patient has risen suddenly, emptied the bladder, and fainted or even 
died in syncope. 

In some cases a cumulative action occurs, which consists in a sudden 
development of the effects of the drug to an excessive degree, so that 
the symptoms resemble those seen after a poisonous dose has been 
taken. This is particularly prone to occur when ascites or dropsy is 
removed by tapping after the drug has been taken for a long period. 
It is thought that the sudden withdrawal of pressure upon the great 
vascular trunks of the body-cavities causes the absorption of the drug 
with the juices of the tissues where it has remained inactive. Such 
an accident also sometimes occurs when a fever ends by crisis and 
digitalis has been given. It also takes place whenever full doses are 
given so frequently as to be in excess of elimination, for the drug is 
slowly eliminated, and so rapidly accumulates in the body. Cumu- 
lative action is often preceded by a scanty passage of urine. A decrease 
in the quantity of the urine when digitalis is being freely used should 
cause the physician to stop its administration or be most cautious in its 
continuance. 

Contraindications. — In cases of marked atheroma of the bloodvessels, 
in aneurism and apoplexy digitalis must be used with care because it 
increases circulatory vigor, and it is because of this effect that it is 
17 



258 DRUGS. 

harmful in the presence of arterial excitement. In fatty degeneration 
of the heart the remaining healthy muscular fibres of this organ are, 
it is true, stimulated by the drug, but it may also increase arterial 
tension to such an extent as to increase the labor of the failing heart. 

Administration. — The official preparations of digitalis are the tincture 
(Tinctura Digitalis, U. S. and B. P.), dose 5 to 30 minims (0.3-2.0); 
the infusion (Infusum Digitalis, U. S. and B. P.), 1 to 4 drachms 
(4.0-16.0); the fluidextract (Fluidextractum Digitalis, U. S.), dose 1 
to 4 minims (0.05-0.25) ; and the powdered digitalis leaves {Digitalis 
Folia, B. P.), dose | to 2 grains (0.03-0.12), generally given in a pill. 

Some choice should be exercised in the use of the various prepara- 
tions made from digitalis leaves, because the different active ingredients 
of the drug possess different solubilities and exert different effects on 
the circulation. Thus digitalin, digitoxin, and digitalein all act as 
powerful stimulants to the heart muscle. Digitalin also stimulates 
the vagus peripherally and centrically. All three of these raise arterial 
pressure by stimulating the vasomotor system peripherally and centri- 
cally. Digitonin, on the other hand, does not stimulate the heart 
muscle, but rather depresses it. It also depresses the vagus, and thereby 
somewhat antagonizes the digitalin, 1 digitoxin, and digitalein. 

If we now turn to a consideration of the solubilities of these prin- 
ciples, we can readily explain the different effects produced by the 
infusion and tincture or fluidextract. Digitonin is soluble in water, 
as is digitalein; but digitalin is only slightly soluble and digitoxin is 
scarcely at all soluble in water. As a result, the use of the infusion 
in a case of heart disease would not give the patient the same degree 
of cardiac power as the use of the tincture, for not only would the 
most powerful stimulant of all to the heart, vasomotor system, and 
vagi — namely, digitalin — be present in small amount, but in addi- 
tion the large proportion of digitonin would antidote it. On the other 
hand, digitonin is sparingly soluble in alcohol, while digitalin and 
digitalein are readily soluble in it, digitoxin being slightly so. It would 
seem, therefore, that in the presence of a failing heart and circulation 
the tincture and the fluidextract are the preparations greatly to be 
preferred to the infusion, because they contain large amounts of the 
active stimulant ingredients. 

The reason that the infusion acts efficiently as a diuretic in some 
cases probably depends upon the fact that as it does not contain so 
much digitalin it is less apt to cause spasm of the renal vessels; but if 
the heart is feeble and there is renal stasis, the tincture is probably the 
better preparation to overcome this state, because it both aids the heart 
and by contracting the renal vessels overcomes the stasis. The use 
of digitalin is inadvisable unless we are sure that we get that made 
according to the process of Schmiedeberg, for the other digitalins usually 

1 By digitalin, reference is made to that prepared by Merck, and sometimes called the 
digitalin of Schmiedeberg, and not the amorphous form of Homolle nor the crystalline 
digitalin of Nativelle. 



DIGITALIS. 259 

sold are very uncertain. The infusion is far more apt to disorder the 
stomach than the fluidextract or tincture, because of the irritating 
digitonin. The dose of digitalin, which ought not to be used as a sub- 
stitute for digitalis, is ¥ V grain (0.001). 

Much confusion exists as to the names applied to the various de- 
rivatives of digitalis. There appear to be no less than four distinct 
substances upon the market called "digitalin," and they differ greatly 
in power. Thus, "German crystalline digitalin" is really digitonin, 
that is, a saponin. French crystalline digitalin is digitoxin and corre- 
sponds to Nativelle's digitalin. French amorphous digitalin purum is 
seemingly a mixture of digitalin and digitoxin and equals Homolle's 
digitalin. German amorphous digitalin purum is a mixture of true 
digitalin and digitalein with 50 per cent, of amorphous digitonin. 
Digalen (dose of solution 1 to 2 mils.) is said by Robert to be a solution 
of digitalein in water, but Cloetta thought it to be soluble digitoxin. 
Digipuratum (dose \\ grains (0.1) or in liquid form 1 mil.), according to 
Grier, is a mixture of digitoxin and digitalin. All these facts indicate 
pretty clearly that the physician should use none of these products, 
but rely on galenical preparations of digitalis leaves. 

When digitalis cannot be given by the mouth there is little use in 
giving any of the official preparations hypodermically, for they are 
precipitated in the tissues. Absorption of digitalis may be brought 
about by the use of a poultice made by placing some digitalis leaves in 
a small bag and steeping them in hot water. The bag is then placed 
over the loins. This plan of treatment must be cautiously employed 
to avoid poisoning, because one cannot tell how much digitalis is 
being absorbed. 

Under the name of "Digitalone," Houghton has devised an excellent 
preparation of digitalis, now on the market, suitable for use by the 
mouth or hypodermic needle, since it represents the full therapeutic 
value of the drug, and is readily absorbed without causing irritation, 
which is not true of tincture of digitalis. This product is "fat-free," 
and is standardized by well-recognized pharmacological tests upon the 
lower animals. 

Digitalone is put up in hypodermic tablets of y 1 ^- grain (0.0065), 
corresponding to about 3 minims of tincture of digitalis and \ grain 
(0.03), corresponding to about 16 minims of tincture of digitalis. 
It also appears in tablet triturates of \ grain (0.012). 

Attention has already been called to the necessity of using a prepara- 
tion which has been subjected to a physiological test by the manufac- 
turer before it is placed on the market. This is important because the 
crude drug varies so greatly in strength that even the most careful 
pharmacist cannot be sure that each lot of leaves is of equal medicinal 
strength, and chemical analysis of their complex make-up is practi- 
cally impossible. Often when a patient has been taking an ordinary 
preparation of digitalis without good results the writer has seen the 
use of a physiologically tested and active preparation do much good. 



260 DRUGS. 



DIONIN. 



Dionin, or JEthylmorphinve Hydrochloridum, U. S., is an artificial 
product derived from morphine, and occurs as a white crystalline, 
faintly bitter powder. It is soluble in about 8 parts of water, 20 of 
alcohol, and slightly soluble in ether and chloroform. 

Dionin is used for several purposes in medicine, both internally 
and externally. Internally it is employed in the dose of J or f grain 
(0.015-0.045) to relieve excessive cough and pain in the chest, in various 
forms of pulmonary disease. It has also been used as a substitute 
for morphine in various painful affections of the internal viscera, as in 
ulcer and cancer of the stomach and bowel, in cases in which morphine 
cannot be used because of nausea. It is said to be equally efficient 
with morphine in the relief of pain but less powerful for the purpose 
of producing sleep. It may also be given to fortify veronal and 
sulphonal in cases of insomnia. In the dose of 1 grain (0.06) dionin 
may be used in suppository in painful conditions of the rectum. 

Externally dionin finds its chief use in the eye. It has been found 
especially valuable in certain types of ulcerative and parenchymatous 
keratitis, iridocyclitis, and glaucoma when used in solutions varying 
from 1 to 5 per cent. This solution is dropped into the conjunctival 
sac two or three times a day. At first it causes a sharp reaction 
with a sense of burning and marked oedema of the conjunctiva, which, 
however, subsides in about twenty minutes, and analgesia, not 
anaesthesia, develops. That is, it relieves pain, but does not locally 
anaesthetize, as does cocaine. When it is used mixed with cocaine, 
both an anaesthetic and analgesic effect is obtained. Immunity to its 
irritant effects is so soon established that its use on subsequent days 
causes little or no irritation. 

If the patient is hypersensitive, the primary painfulness of dionin may 
be prevented by preceding its use by cocaine solution. It is also ad- 
visable to drop the dionin solutions into the conjunctival sac so as to 
avoid the cornea, which is much more sensitive to its effects than the 
conjunctiva. Dionin may be added to solutions of myotics or mydri- 
atics when it is desired to relieve eye pain at the same time that the 
beneficial effects of the other drug are obtained. 

DIURETIN. 

(See SODIO-SALICYLATE OF THEOBROMINE.) 

DORMIOL. 

This drug is closely related to chloral, being a compound of chloral 
and amylene hydrate, and is a colorless fluid, tasting somewhat like 
camphor and being slightly pungent to the oral mucous membrane, 
It is miscible with water, and is marketed in 50 per cent, watery solu- 
tion, which is further diluted by 4 additional parts of water when it is 



ELATERIUM 261 

prescribed. It is used as a hypnotic, as its name indicates, and as a 
substitute for chloral, but is probably not so powerful as a sleep- 
producer. Its dose is J to 1 drachm (2.0-4.0) of the 10 per cent, 
solution just named, which may be mixed with syrup of raspberry, 
or water, to dilute it if desired. 

DUBOISINE. 

Duboisine is the alkaloid of the leaves of Duboisia myoporcides, a 
plant of Australia. The crude drug is little used in medicine, but 
duboisine sulphate is used as a mydriatic under the same conditions as 
is atropine, and more largely still as a hypnotic in insanity, inter- 
changeably with hyoscine. The dose of duboisine sulphate hypoder- 
mically as a hypnotic is -gV to ^ grain (0.0008-0.001). The clinical 
experience so far adduced would seem to indicate that it tends to 
decrease urinary secretion and to disorder the digestion, producing at 
the same time a soapy taste in the mouth, with excessive dryness of the 
mucous membranes/ Rarely it causes profuse salivation or sweating 
in those who have an idiosyncrasy to its use. In a large number of 
insane and hysterical cases de Montyel found its use was followed by 
vomiting of part of the food, but the patients seemed to have no nausea. 
The sulphate has been used with much asserted success in the treat- 
ment of paralysis agitans. Usually the dose by the mouth for this pur- 
pose has been y^- grain three times a day. Cividati and Gianelli assert 
that duboisine is useful in epilepsy, particularly in its psychic forms. 

ELATERIUM. 

Elaterium, B. P., is a sediment obtained from the juice of Ecballium 
elaterium, or squirting cucumber. It appears in small, friable, thin, 
grayish-green flakes, having a bitter taste. Elaterium is not official 
in the U. S. P., but its active principle, elaterin (Elaterinum, U. S. 
and B. P.), is official. Elaterin is a neutral principle deposited by 
the juice. Notwithstanding this fact, the crude drug is largely used. 

Physiological Action. — Elaterium is a decided irritant to all mucous 
membranes, and even to the fingers of those who handle it. Its chief 
effect when taken internally by man is to cause profuse watery stools, 
but for some unknown reason it rarely acts upon animals in this 
manner. 

Therapeutics. — This drug is the best hydragogue purge which we 
have, causing large watery passages, but not producing much pain 
when used in proper dose. For this reason it is useful in the treat- 
ment of local serous transudations. In serous effusions due to acute 
or chronic inflammatory processes it is of little value because in such 
cases the stomata of the serous membranes involved are closed by fibrin, 
as in pericarditis and pleurisy. In dropsy and ascites or general anasarca, 
it may be useful. It ought never to be used in cases of marked exhaus- 



262 



DRUGS. 



Fig. 42. 



tion,and may be advantageously followed, soon after it acts, by alcoholic 
stimulants. In uraemia with dropsy it is thought to aid in the elimina- 
tion of the urcemic poison by the bowel. In cerebral congestions or 
effusions the drug is of service by depleting the diseased vessels. 

In poisoning by elaterium the symptoms are those of violent gastro- 
enteritis, and must be treated accordingly. (See Gastro-enteritis.) 

Administration. — The dose of elaterium is J grain (0.01), given in a 
freshly made pill. Elaterin is best given in the dose of from 2V to ^ 
grain (0.003-0.006), as follows: 

1^— Elaterini . gr„ iv (0.25). 

Alcoholis f 5iv (120.0).— M. 

Dissolve by gentle heat. 
S. — Half a drachm contains T V grain (0.004), or one full dose. 

The official preparation of elaterin, the active principle of elaterium, 
is Trituratio Elaterini, U. S. (elaterin 1, sugar of milk 9), given in the 
dose of \ to 1 grain (0.03-0.06). Pulvis Elaterini Compositus, B. P. 
(elaterin 1, sugar of milk 39), is given in the dose of 1 to 5 grains 
(0.06-0.3). 

ERGOT. 

Ergota, U. S. and B. P., is derived from the spawn or mycelium of 

the fungus known as Claviceps purpurea, which grows in the flower 

and replaces the grain in common rye, or 

Secale cereale. After being kept for a year 

crude ergot is not fit for use. 

Many so-called active principles of ergot 
have been isolated by chemists, and named 
ecbolic acid, ergotic acid, sclerotinic acid, and 
ergotin. None of these represent the entire 
drug, the nearest in its approach being ergo- 
tin, and ergotin is not an isolated principle, 
but a combination of principles. According 
to Wood and Hofer the active ingredients are 
an alkaloid and a resin which exist in combi- 
nation. Jacobi calls this combination spha- 
celotoxine. For the alkaloid Kraft suggests 
the term hydro-ergotinine, sometimes called 
ergotoxine. 

Physiological Action. — Nervous System. — 
Upon the nervous system ergot exercises 
little, if any, effect. 

Circulation. — Ergot, when injected into 
the circulation causes a primary fall of arterial 
pressure, followed by a slight rise. This rise 
is probably due to a stimulation of the muscu- 
lar coats of the bloodvessels, but the primary 
fall is caused by its direct depressant effect 
upon the heart muscle, resulting from the direct contact of the drug 
en masse with the heart. If the dose be very large, and the fall of 




A, ergot stimulates the 
uterine centres in the spinal 
cord, and B, the muscular 
fibres in the uterus itself. 



ERGOT. 263 

pressure is not recovered from, progressive paralysis of the vasomotor 
apparatus and heart occurs. When given in medicinal doses by the 
stomach the drug causes a slight rise of arterial pressure, chiefly by an 
action on the heart and the muscular coats of the bloodvessels, but 
this effect would seem to be too feeble to be of much value in bedside 
practice. 

Uterus and Unstriped Muscular Fibre. — It has been commonly 
taught that the contractions of the uterus produced by medicinal 
doses of ergot are due to the stimulating influence of this drug upon 
the muscular fibres of this organ; but Dale seems to have proved that 
the influence is exercised on the nerve-endings in the muscles. It is 
also a fact, as shown by the careful studies of Hemmeter, that the drug 
causes uterine contractions by stimulating the centres in the lumbar 
portion of the spinal cord which controls this viscus. 

On the uterus ergot in full medicinal dose exerts its influence not by 
increasing the normal pains of labor, but by causing a tetanic, tonic, 
unyielding uterine spasm which drives all before it. In very small 
doses it may assist the normal contractions without causing them to 
become tetanic. 

Ergot acts as a stimulant to all unstriped muscular fibres. 

Acute Poisoning. — The symptoms of overdosing from ergot, when 
the effects are slowly produced, are sometimes great hunger or craving 
of food, at other times nausea and vomiting. If the poisoning is quite 
severe, there are great restlessness, headache, delirium, and coldness 
of the surface of the body. 

Chronic Poisoning.— Two forms of poisoning from the prolonged 
use of ergotized rye bread sometimes occur. One is characterized by 
spasmodic muscular contractions, the other consists in the formation 
of gangrenous sloughs. In the first of these forms it is not very uncom- 
mon for cataract to develop, and it is stated that the spasms are due to 
the influence of one of the principles of ergot — namely, cornutine. 

Therapeutics. — Ergot is given to parturient women for the prevention 
or arrest of post-partum hemorrhages. For the prevention it should be 
given to the woman by the mouth after the delivery of the head, but 
in many instances its use is needless. When administered to check a 
hemorrhage already flowing, the doses shop Id be large, as much as 
1 to 2 drachms (4.0-8.0) of the fluid extract or 1 wineglassful (30.0) 
of the wine of ergot. The drug should produce its effects in about 
fifteen minutes, and may be repeated every fifteen minutes until it acts. 
The action lasts about half an hour. Ergot should not be given in 
the early stages of kbor, but this rule may, under certain conditions, 
be modified. If uterine inertia comes on in the course of a normal 
labor, which cannot be overcome by the use of coffee or strychnine, 
or other nerve-stimulant, a small dose of ergot may be employed. 
Such small dose does not cause a constant tetanic uterine contraction, 
but simply brings on the "to-and-fro" movements. By a " small dose" 



264 DRUGS. 

the writer means from 5 to 20 minims (0.3-1.3) of the fluidextract. 
Caution must be used even with this dose. 

If the birth-canal is obstructed, ergot should never be employed, 
and, unless the os uteri is well dilated, it should not be given in any 
dose. 

In postpartum hemorrhage it is well to give "Ergot Aseptic" or 
"Ergone" hypodermically. "Ergot Aseptic" is dispensed in sealed 
and sterile glass ampoules, and is a concentrated preparation of ergot 
intended for hypodermic use. Each bulb holds one dose, and the 
drug is drawn directly from it into the syringe. This is a most useful 
preparation, physiologically tested and twice as strong as the fluid- 
extract, U. S. P. 

When ergot is given, care should be taken that the uterine cavity 
is free from all clots or placental fragments, lest closure of the os 
uteri under the influence of the drug imprison these harmful materials. 

According to many obstetricians, whose results have been confirmed 
by a number of special studies, ergot in moderate doses very distinctly 
aids in overcoming subinvolution of the uterus. 

In hemorrhages from the lungs and kidneys or other unapproachable 
parts ergot is thought by some to be very useful when given by the 
mouth, but it is probable that it rarely achieves any good. Par- 
ticularly is this the case in pulmonary hemorrhage, since a vaso- 
motor system practically does not exist in the pulmonary vessels, and 
the increased pressure caused by the ergot in the general systemic cir- 
culation may increase the pulmonary leakage. The truth is, that in 
pulmonary hemorrhage little real good can be obtained by the use of 
vasoconstrictors. 

In epistaxis, menorrhagia, and metrorrhagia, and in some cases of 
night-sweats, ergot is of service. In hypostatic, pulmonary, and other 
congestions it is useful, particularly if used with digitalis. * In dysenteries 
with bloody stools and in serous diarrhea ergot sometimes does good. 

Some persons suffer from vertigo associated with hyperesthesia of 
the scalp and headache. Relief can often be obtained in such cases by 
the use of 20 minims (1.3) of the fluidextract of ergot and 5 to 10 grains 
(0.30-0.60) of bromide of potassium three times a day. 

Ergot has been used very largely in the treatment of uterine fibroids 
as an expulsive remedy and cure. It is only cf value in those cases 
where the growths are just beneath the mucous membrane. By the 
contractions of the uterine muscular fibres the blood-supply of the 
growth is decreased, the recurring hemorrhages cease, and the tumor 
is finally expelled, having sloughed out of its bed. This method is 
far inferior to the knife, and very painful and prolonged. Large 
growths cannot be so treated. Ergot is sometimes useful in the treat- 
ment of bleeding hemorrhoids, and in diabetes insipidus, in which dis- 
ease it is well to combine with it the bromide of sodium. 

Administration. — Ergot is official as the fluidextract (Fluidextractum 
Ergotw, U. S.; Extractum Ergotoe Liquidum, B. P.), dose \ to 1 drachm 



ETHER. 265 

(2.0-4.0), 10 to 30 minims (0.6-2.0), B. P.; and the extract (Extractum 
Ergotce, U. S. and B. P.), dose 5 to 30 grains (0.3-2.0), 2 to 8 grains 
(0.12-0.48), B. P. Bonjean's egotin is made by a special process, 
and it can be given hypodermically if "Ergot Aseptic" or "Ergone" 
cannot be had. The B. P. preparations are Infusum Ergotce, 1 to 2 
•fluidonnces (30.0-60.0), arid Injectio Ergotce Hypodermica, B. P., 
given in the dose of 3 to 10 minims (0.20-0.60) by subcutaneous 
injection. The B. P. also recognizes an ammoniated tincture of ergot 
(Tinctura Ergotce Ammoniata) . Ergotin (Ergotinum) is given in the 
dose of 2 to 5 grains (0.12-0.30). 

As ergot is a drug that varies greatly in physiological activity in 
its crude state, and cannot be chemically assayed with advantage, the 
physician should always use a preparation which has been physiologi- 
cally tested by the manufacturer before it is placed on the market. 
This may be done by studying its effect on the uterus of a pregnant 
animal, or by giving it to animals and observing its effect on the calibre 
of the small vessels. If the drug is active, it causes stimulation of the 
muscular coats of the vessels; and if its use is persisted in, it finally 
occludes them. Houghton has shown that an active ergot will cause 
gangrene of the rooster's comb if it is given constantly. Inert ergot" 
will not do this. Much credit is due to Houghton for having perfected 
this valuable pharmacological test. 

The younger Wood asserts that the fluidextract loses 10 per cent, a 
month in strength even when it is kept hermetically sealed in a bottle. 
A fresh preparation is therefore essential. 

ERIGERON, OR FLEABANE. 

Oil of erigeron is a yellowish volatile oil of a peculiar, not unpleasant, 
taste, closely resembling that of turpentine, which is distilled from the 
fresh flowering herb of Erigeron canadense. It may be used as a 
remedy for the treatment of passive uterine oozing, or a "show," as 
it is sometimes called. In epistaxis and other hemorrhages of mod- 
erate degree it is useful. In some instances it is used in place of 
copaiba and cubebs in the later stages of gonorrhoea. It is best given 
in capsule or on sugar in the dose of 10 to 30 minims (0.60-2.0) after 
meals, or oftener if needed. 



ERYTHROL TETRANITRATE. 

(See article on Nitroglycerin.) 

ETHER. 1 

Sulphuric ether is official as MJier, U. S., and Mher Piirificatus, 
B. P., and in the U. S. Pharmacopoeia of 1880 was called Mher 

1 The student should read the article on Chloroform in conjunction with this article 



266 DRUGS. 

Fortior. It is a liquid composed of about 96 per cent., by weight, 
of absolute ether or ethyl oxide, and about 4 per cent, of alcohol 
containing a little water. It should be kept in partially filled, well- 
stoppered containers, preferably tin cans, in a cool place, remote from 
lights or fire. It is a transparent, colorless, mobile liquid having a 
characteristic odor, and a burning and sweetish taste, and is soluble in 
about 12 times its volume of water at 25° C. (77° F.), with slight contrac- 
tion of volume. It is miscible in all proportions with alcohol, chloro- 
form, petroleum benzin, benzene, fixed and volatile oils. Ether boils 
at about 35° C. (96° F.), and it should, therefore, boil when a test- 
tube containing some broken glass and half filled with it, is held for 
some time closely grasped in the hand. 

Ether is made by the action of sulphuric acid on ethylic alcohol. 

It is highly volatile and inflammable. Its vapor, when mixed with 
air and ignited, explodes violently. The color of light blue litmus 
paper moistened with water should not be changed to red when the 
paper is immersed in ether for ten minutes. Upon evaporation, 
ether should leave no residue. If 10 mils, of it be poured, in portions, 
upon clean odorless blotting paper, and allowed to evaporate spon- 
taneously, no foreign odor should be perceptible when the last traces 
of ether leave the paper. 

Ordinary ether is not used as an anaesthetic, but for the abstraction 
of oils and for other pharmaceutical purposes. It contains about 74 
per cent, of ethyl oxide and 16 per cent, of alcohol, with a little water. 

Owing to its inflammable nature ether should never be held near a 
fire or light, and, as its vapor is heavier than air, any flame in the room 
should be above the patient, not below him. No flame should be 
held nearer to the ether than five feet. 

Physiological Action. — The action of ether on the animal organism 
when its vapor is inhaled is very rapid and powerful, but fleeting. 
When applied to the skin it causes intense cold if allowed to rapidly 
evaporate, and may be used in the form of a spray to benumb sensation. 

The passage of ether vapor into the blood by way of the lungs de- 
pends upon the law governing the partial tension of gases. If the air 
in the alveoli of the lungs contains a given per cent, by volume of ether, 
there will be a tendency for the blood in the bloodvessels of those alveoli 
to take up this vapor until the percentage is the same in the blood as it 
is in the air of the alveoli. If, on the other hand, the blood contains 
more ether vapor than the air, the vapor will tend to pass from the 
bloodvessels to the alveoli. This explains why it is that in accidents 
during ether anaesthesia artificial respiration, by forcing out the ether- 
laden air of the alveoli, aids the blood in getting rid of poisonous 
amounts of the drug and so directly tends to restore the patient. 

Upon mucous membranes ether as a liquid or in vapor acts as an 
irritant, and causes, when its concentrated vapor is first inhaled, great 
irritation of the fauces and respiratory tract, so that temporary arrest of 
respiration is not uncommon. The face becomes suffused and red and 



ETHER. 



267 



the conjunctiva injected. Owing to these conditions the patient often is 
restless or struggles to move his face away from the vapor, but a stage of 
quiet soon succeeds this primary stage of struggling. During this period 
of quiet the breathing is generally full and deep and the pulse rapid but 
strong, while the ocular reflexes are at its beginning intact. Following 
this stage a second period of restlessness or struggling may come on, 
in which the patient becomes absolutely uncontrollable except by brute 
force. Yelling, shouting, cursing, or laughing and crying, may be 
prominent symptoms, and the individual is pugilistic, caressing, or 
ill-tempered, according to his temperament. If the drug is now pushed 
a condition of total unconsciousness and anaesthesia is soon attained, 
and quietude takes the place of the struggles. This is the time for 
the operation to be carried on, for if it is attempted in the earlier 
stages the struggles of the second stage prevent any operative procedures. 
(See Therapeutics, below.) It is not proper to push the drug until the 
muscular relaxation amounts to complete flaccid ity, as this endangers 
the respiration. 

Fig. 43. 





Ether produces anaesthesia by depressing the perceptive areas in the brain, A. Later it 
depresses the intellectual areas, B, and the motor areas, C. After this the sensory paths in the 
spinal cord are depressed, D, and finally the motor tracts in the cord, E. 



Nervous System. — In producing its effects, ether acts first on the 
brain, then on the sensory tracts of the spinal cord, then on the motor 
tracts, then on the sensory side of the medulla oblongata, and finally 
upon the motor side of the medulla, and thereby produces death from 
respiratory failure if given to excess. Upon the nerve-trunks it exerts 
no effect unless it is directly applied to them. Ether does not produce 
anaesthesia by influencing the blood, coagulating the protoplasm of the 
nervous system, or by any other destructive influence. It simply 
inhibits, for the time being, the vital functions of the parts affected by it. 



268 DRUGS. 

The anesthesia from ether develops when the ether vapor is present 
in the blood-serum in the proportion of 1 to 400. (See Chloroform.) 

Circulation. — Ether is one of the most diffusible and rapidly act- 
ing cardiac stimulants which we possess, and is correspondingly fleet- 
ing in its effects. It increases the pulse-rate and force by stimulating 
the heart and the arterial pressure by increasing the activity of the vaso- 
motor centres. This statement has been contradicted by laboratory 
investigators, who claim that ether is never a cardiac stimulant in a 
strict technical sense. However this may be, ether is used and acts as 
a most useful circulatory stimulant in man when it is given by the mouth 
and when inhaled in small amounts. In overdoses it acts as a cardiac 
depressant, but only when the amount is very large. Upon the blood, 
the author's colleague, J. Chalmers Da Costa, has shown that ether, 
when given by inhalation, decreases the haemoglobin richness of each 
corpuscle, although there is an apparent increase in the number of the 
corpuscles themselves, particularly in those persons who are already 
somewhat anaemic. 

Respiration. — As already stated, when ether is first inhaled in con- 
centrated form it often causes arrest of respiration. According to 
Kretzschmar, this is due to an irritation of the trifacial nerve, which 
causes a reflex spasm of the glottis, and not to irritation of the per- 
ipheral vagi in the lungs. This is only partly true, for the author has 
proved that section of the vagus nerves prevents this occurrence, so that 
both the vagal and trigeminal irritations are responsible for the arrest. 

In patients under ether the movement of the diaphragm is an exceed- 
ingly interesting study, for before the condition known as surgical 
anaesthesia is developed, while there is still some rigidity and the 
throat reflex is not completely abolished, the contractions of the dia- 
phragm are frequently so violent that unless the laryngeal opening 
be absolutely free the intercostal spaces are depressed and the abdomi- 
nal contents thrust violently downward and outward. Just so soon, 
however, as the chin is pulled forward and a free access of air is allowed, 
the abdominal displacement, though it is still present, is not so great, 
and the chest movement is no longer reversed. As the ether is pushed 
the respiration becomes purely thoracic, the diaphragm no longer taking 
part in the respiratory cycle, or becoming so relaxed that it allows 
the chest on expansion to aspirate the abdominal viscera upward, 
as is shown by the retraction of the belly-walls at a time when they 
should normally expand with the thorax in inspiration. This obser- 
vation would seem to point to the fact that the primary stimulant 
action of ether upon the respiratory apparatus is particularly felt by 
those centres which govern the movements of the diaphragm, and 
that, as this is the case, these centres later are the first to feel the 
paralyzing effect of still larger amounts of the drug. 

These facts give us, therefore, a danger-signal during the adminis- 
tration of ether, and the integrity of the diaphragmatic function, as 
represented by the movement of the belly-walls, should be as care- 



ETHER. 269 

fully observed as are the thoracic excursions, the character of the 
pulse, or the condition of the pupil. The rule may therefore be laid 
down that when the diaphragm ceases to act, anaesthesia has been 
carried to its extreme legitimate limit, and that the use of an anaes- 
thetic after this time must be carried on with the greatest care and 
watchfulness. 

The diaphragm is the first part of the respiratory mechanism to 
yield to respiratory paralysis. In death from any cause the progress 
of failure of respiration will, in the vast majority of cases, be denoted 
by a failure on the part of the diaphragm primarily, with compensa- 
tory excursions of the chest; and it is also to be noted that as the chest 
movements fail the accessory muscles of the neck come into play. 
These muscles in time cease to act, the hyoidean group lose their point 
d'appui, the chest remains motionless, the lower jaw is dropped, and 
the scene is closed by a few gasps in which the muscles of the neck 
may be the chief factors. 

Upon the respiratory centre ether acts as a powerful stimulant when 
used in ordinary amounts; in overdose it paralyzes this part of the 
nervous system. 

Temperature. — Prolonged etherization lowers the bodily heat very 
greatly. That of the dog may be lowered some 9° F. in an hour 
if the drug be pushed, and as great a fall has been known as 4° F. 
in man. The fall is partly due to the depression of the nervous sys- 
tem and the chilling of the body and lungs by the evaporation of 
the drug. 

Elimination. — Ether escapes from the body by the lungs and 
kidneys, chiefly by the lungs. 

Untoward Effects. — Ether, while safer than chloroform, is not abso- 
lutely devoid of dangerous effects. 1 Sometimes, when the drug is 
pushed too strongly, deep cyanosis with pulsation of the jugular veins 
shows deficient oxygenation of the blood and cardiac distention. In 
other, very rare, instances sudden cardiac failure has occurred or total 
arrest of respiration ensued. In nearly all cases of sudden death from 
ether grave kidney or heart lesions have been found at the autopsy. 
Rarely the rise of arterial pressure which it produces has caused 
apoplexy. 

The treatment of accidents during etherization consists in the with- 
drawal of the ether, the use of artificial respiration, and the placing 
of the body, if the face is pale, head downward. On the other hand, 
if the face is flushed and cyanotic it indicates respiratory, not cardiac, 
failure, and this position is not to be resorted to. The physician should 
also employ hypodermic injections of strychnine, atropine, and 
digitalone, or more rarely, an intravenous injection of ammonia, which 
is more dangerous, but better than the others in a pressing emergency 

1 The mortality due to etherization is about 1 in 20,000; or, according to the combined 
statistics of Julliard and Ormsby, in 407,553 cases there were 25 deaths, or 1 in 16,302. 
(Compare Chloroform.) 



270 



DRUGS. 



because it is more rapid in its action. Ether is often given hypoder- 
mically under such circumstances, and may occasionally do good; 
but its use is a bad practice, for if the heart or respiration is already 
depressed by ether, the employment of still more of the drug simply 
makes matters worse. The cases in which such a line of treatment 
is followed by good results are those in which the failure of respiration 
is not due to a saturation of the body with ether, but to asphyxia pro- 
duced by mechanical interference with free breathing, as, for example, 

Fig. 44. 




Illustrating how traction on the tip of the tongue draws the epiglottis away from the glottic 
opening and permits free ingress of air. Also showing how letting the tongue fall back in the 
mouth in anaesthesia would close the air-passages and permit the epiglottis to interfere with 
breathing. (This is important.) For a full description see article on Asphyxia. (From a 
research by Martin and the author.) 

the presence of mucus in the air-passages or a too close application 
of the inhaler to the face. In such cases the hypodermic injection of 
ether causes so much local pain and irritation as reflexly to excite 
respiratory movements, as well as to stimulate directly the respiratory 
centre to greater effort. 2 Alcohol ought not to be used if the other 
drugs named can be obtained, because alcohol is so nearly allied 
physiologically and chemically to ether. Frictions, hot applications, 
and artificial respiration should be practised. (See article on Asphyxia.) 



1 As consciousness is not necessary to the carrying out of a reflex action, this is per- 
fectly possible and probable. 



ETHER. 271 

The diaphragm being the most important muscle of respiration, the 
physician should seek to stimulate it by resorting to Laborde's rhythmic 
traction of the tongue, which consists in rhythmically drawing the 
organ outward and upward from the mouth ten to fourteen times a 
minute. 

As ether is at hand, it may be dashed on the chest and abdomen, 
to cause inspiration by reflex action, in lieu of cold water, which 
wets the clothes and does not evaporate rapidly. 

In about 30 to 40 per cent, of cases nausea and vomiting follow the 
use of ether. This can generally be prevented by the avoidance of 
food for twelve hours before an operation, and by the administration 
of cracked ice and small doses of acetanilide and brandy after the opera- 
tion. (See Vomiting.) This condition may also be avoided in many 
cases by giving oxygen gas with the anaesthetic. (See Oxygen, Im- 
portant.) Severe bronchitis may occur in invalids and children after 
the inhalation of ether, and in many cases this is due more to exposure 
than to the drug. Pulmonary complications, while possibly due to 
the direct effect of the ether, are probably chiefly the result of the 
inspiration of particles of food, foul secretions from the mouth, and 
perhaps blood, into the lungs, the glottis being anaesthetized and unable 
to protect the lungs from the invasion of foreign matter. Great cleanli- 
ness of the mouth is essential before every operation, and care should 
be taken during and after an operation that septic materials are not 
inspirated. It is wise to order a peroxide of hydrogen mouth-wash. 

Total or partial anuria may develop after etherization, particularly 
after abdominal operations. This is a very dangerous symptom, 
which can sometimes be removed by giving nitroglycerin, to relax 
spasm of the renal vessels, and a large rectal injection of normal saline 
solution. It has, however, been proved, both experimentally and clinic- 
ally, that ether is not capable, in the ordinary patient, of producing 
renal disorder of any moment unless the kidneys are already diseased 
or the patient is soaked with the drug, as sometimes occurs when it is 
improperly given. Weil asserts that ether is not dangerous even in 
those with moderately diseased kidneys but in a goodly proportion of 
cases the use of ether diminishes urinary flow and decreases the escape 
of solids even more than it decreases the elimination of liquids. The 
employment of ether in diabetic patients is dangerous; the patient often 
never regains consciousness after its use. Post-anaesthetic toxaemia may 
arise after the use of ether. Cases have been reported by Brachett, 
Stone, Low, and others. (See Chloroform for Post-anaesthetic Tox- 
aemia.) 

Not uncommonly after the use of ether in the case of an old person 
or a child the bronchial tubes so fill with mucus that there is danger 
of the patient drowning in his own secretions. A full dose of atropine,, 
which checks secretion, given hypodermically, is useful at such times, 
and may be used beforehand as a prophylactic. 

Sometimes after an anaesthetic is given the patient is found to have 



272 



DRUGS. 



a monoplegia. This is not due to the anaesthetic, but to pressure 
exercised upon the nerve supplying the part during the anaesthesia. 
It is a true pressure-palsy. 

Administration. — In giving an anaesthetic it is of the greatest impor- 
tance that the patient shall not be frightened or made nervous by its 
too free use at first, and it is better in nervous women and children 
to produce anesthesia while they still remain in bed, so that the sight 
of the operating-room will not disturb them. By this means not only 
nervous strain is avoided, but fearful "nightmares" while under the 
effects of the drug are prevented. The greatest gentleness should be 
exercised and the mind diverted, if possible, by some pleasant thoughts. 

Ether is used chiefly as an anaesthetic by means of inhalation. 



Fig. 45. 



Fig. 46. 





Allia inhaler. 



Safety-pin to make ether-dropper 
out of ordinary can. 






The best plan of administration is by the so-called "drop method." 
This consists in using an Esmarch inhaler (see Chloroform), and 
allowing the ether to fall drop by drop upon its surface in the same 
manner that chloroform is used, but somewhat more freely. By 
this means the patient escapes disagreeable oppressive sensations 
at the beginning of the administration and, more important, the 
nausea and vomiting during and after anaesthesia are greatly dimin- 
ished as to frequency of occurrence and severity, as is also the danger 
of renal and respiratory irritation and post-anaesthetic toxaemia. In 
other words, the patient is not in danger of being poisoned by an excess 
of the drug, but is kept under its effects only sufficiently to avoid pain, 
restlessness, and voluntary movement. The disadvantages of this plan 
are that it takes longer to anaesthetize the patient, uses more ether, and 
is often not adequate in those addicted to narcotics or for powerful 
men. It is, however, peculiarly suitable to women and children. The 
use of an " Allis inhaler" (Fig. 45) enables us to use the "drop method" 
in the more resistant patients because larger amounts of ether can be 



ETHER. 273 

given and yet the patient receives plenty of air. There is no justifica- 
tion in giving the ether so freely as to cause a sense of suffocation and 
fear. The better way is to hold the inhaler at some distance from the 
face, and gradually bring it nearer as the effects of the ether are devel- 
oped. As the vapor of ether is heavier than air, it falls over the patient's 
face in concentrated form, even if the distance between the inhaler 
and the patient amount to several inches. There is, therefore, no justi- 
fication in applying the cone to the face at the very beginning of the 
inhalation. After partial anaesthesia is attained, the inhaler should 
be placed closely over the face and the vapor be pushed in a more con- 
centrated form for a brief period. Care should be taken that the ether 
does not get into the eyes of the patient, either in vapor or liquid form, 
owing to the irritation which it will set up. To prevent this a piece of 
thin muslin wet with water will be found of service if placed over the 
eyes. 

Much of the irritation of the upper respiratory passages produced 
by ether may be avoided by wetting the inhaler with a drachm or two 
(4.0-8.0) of an alcoholic solution of menthol (2 per cent.). 

When ether is to be given no solid food ought to be allowed the patient 
for twelve hours preceding its use, in order to avoid vomiting during 
and after the operation, but easily assimilated liquid carbohydrates, 
such as barley or rice gruel, may be given later than this with advantage 
(See Chloroform.) 

The patient should not be allowed to retain any foreign body or arti- 
ficial teeth in the mouth, as they may slip into the larynx and cause 
death while the anaesthetic is being given. 

"When a general anaesthetic is used to prevent suffering, it should be 
remembered that, although it prevents the intellectual centres from 
appreciating pain by blotting out consciousness, and so puts aside 
psychic shock, it does not prevent painful impulses from reaching the 
spinal cord and medulla oblongata, the latter being a most vital spot. 
In delicate persons or in severe operations it is often advisable to block 
these impulses by injecting procaine into or around the tributary 
nerve, thereby protecting the central nervous system. Some physi- 
cians used morphine hypodermically before operation to benumb the 
patient's sensibilities with the hope that less ether will be required. 
This is wise in some cases when great anticipatory dread is felt, but in my 
experience ''straight anaesthesia" is the safest plan. Instead of push- 
ing the anaesthetic so that very deep anaesthesia is produced when an im- 
portant nerve or organ is attacked, it is better to let up at this moment, 
since by this means pain is prevented, but the lower vital centres are 
not subjected to both shock and the drug in large amounts at the 
same moment. 

In operations on the upper air-passages, and those involving the 
thoracic cavity, the method of intratracheal insufflation is now largely 
resorted to, since by this means anaesthesia and respiration can be car- 
1S 



274 



DRUGS. 



ried out even if the patient stops voluntary respiration. Before the 
instrument is introduced into the larynx this organ should be carefully 
examined to determine its size, its healthfulness, and the absence of 
deformity. The patient should be anesthetized by the ordinary open 
method. The head should be sharply flexed backward on the neck, and 
the neck extended by drawing the head from the trunk. The occiput 
remains on a plane with the table, but the cervical vertebrae are arched 



Fig. 47. 




TA-QV.C 

Schema illustrating the direction ot motion to be imparted to the laryngeal speculum in exposure 
of the larynx for the introduction of ether insufflation tubes. (Chevalier Jackson.) 

forward. Jackson insists that no gag should be used, as it presses 
down the lower jaw. The speculum must be passed beyond the epi- 
glottis, but not far enough to lift the cricoid cartilage. Holding the 
speculum in the left hand, the operator with his right hand elevates 
the upper lip of the patient so it will not be pressed against the teeth. 
The spatula portion of the speculum is passed back over the tongue 
half an inch beyond the tip of the epiglottis. 

The soft catheter through which the anaesthetic and air is passed 
is now inserted. 

A very cumbersome and complicated piece of machinery has been 
invented to deliver warm air-pressure ether vapor through the catheter. 
In an emergency the ether can be put in a Wolff bottle, which is im- 
mersed in warm water (not hot) , and connected with an ordinary bulb 
and rubber reservoir, such as is used with an atomizer or Paquelin cau- 
tery. By this means the air is driven through the warmed ether and 
can pass to the rubber catheter introduced into the larynx. 

Under the name of the A. C. E. mixture there is used a compound 
of alcohol, chloroform, and ether, which is but rarely used in America. 
(See Chloroform.) 



ETHER. 275 

Ether may be used as a local anaesthetic in an atomizer spray, 
owing to the cold produced by its evaporation when it strikes the skin. 
Thus it is particularly useful in cases where thoracentesis or para- 
centesis abdominis is to be performed, and also in cases of superficial 
neuralgia, where the benumbing of the nerve often effects a permanent 
cure. 

Recently ether anaesthesia, induced by injecting ether, 6 ounces, 
and olive oil, 2 ounces, into the rectum has been introduced. This 
largely obviates the irritant effects of the older plan of using ether by 
the rectum. The advantages claimed are promptness of action 
and avoidance of postanesthetic vomiting, as well as a clear field 
in operations about the head and neck. The mixture is introduced 
by means of a funnel attached to a rubber catheter after the bowel 
has been washed clean. If the patient manifests too deep narcosis, 
the mixture is withdrawn by means of a soft-rubber catheter. When 
the operation is over the bowel is washed out with a soapsuds enema, 
and then 2 to 4 ounces of olive oil introduced. The plan is not as safe 
as the inhalation method, as there seems to be much greater danger of 
respiratory paralysis and less opportunity of fitting the dose to the 
needs of each individual. 

Ether may be used by inhalation to produce muscular relax- 
ation when the surgeon desires to reduce a strangulated hernia by 
taxis. 

Internal Administration. — When used internally, ether should be 
given in ice-cold water, or, better still, in capsule, in the dose of 30 
minims to J ounce (2.0-16r0). If cold water is not used to dilute it, 
so great is the irritation of the fauces produced by the fumes of the 
drug that deglutition is impossible. 

Internally, by the stomach, ether is very useful in colic, although 
for flatulence of adults and children Hoffmann's anodyne is a more 
efficient remedy. (See Hoffmann's Anodyne.) In cases of collapse 
ether, given by means of the hypodermic needle or by the stomach, is 
of great service, particularly when cardiac action is very feeble, and it 
will give relief by inhalation in some of these cases more rapidly than 
the nitrite of amyl. 

In hiccough a few inhalations of ether will often stop the spasmodic 
movements, and other local muscular spasms can be relieved in this 
way. In other instances, a few drops scattered over the belly-wall 
may arrest it. 

Large doses of ether given by the mouth or hypodermically have 
been highly recommended in the treatment of uraemia. They are 
most serviceable in the forms in which cardiac and respiratory com- 
plications are marked. 

In cases where cod-liver oil cannot be digested ether may be given 
in 20 minim (1.30) dose in ice-water or capsule, either with the oil, or 
some minutes after it is taken, to aid in its digestion and absorption. 

The Spiritus /Etheris, U. S. and B. P., is given in the dos^ of \ to 2 
drachms (2.0-8.0). (See also Hoffmann's Anodyne.) 



276 DRUGS. 

Contraindications. — Ether should not be used by inhalation in bron- 
chitis or acute nephritis, because of its irritant properties; in perito- 
nitis or gastritis, because it is apt to induce vomiting; in aneurism or 
in the presence of marked vascular atheroma, because it may rupture 
a bloodvessel by raising arterial pressure; nor in diabetes, lest it pro- 
duce diabetic coma; and if anaemia is present and an examination of 
the blood shows that the haemoglobin is below 50 per cent., the use 
of the drug should be avoided if possible. 



ETHYL BROMIDE. 

Mthylis Bromidum is obtained by distilling a mixture of alcohol, 
sulphuric acid, and bromide of potassium, and is a colorless fluid of 
neutral reaction, having a pleasant odor resembling chloroform. It 
evaporates with great rapidity, and any sample which does not do this 
is to be discarded. Poured on the hand, it should leave no fatty feeling. 
It should be remembered that the drug is decomposed by sunlight 
and when in prolonged contact with the air. In the presence of lamp- 
light the fumes form bromal hydrate and bromine. The drug should 
be kept in dark-glass bottles. The physician should distinctly sepa- 
rate in his mind bromide of ethyl from bromide of ethylene. The 
latter is a chemical product possessing very dangerous properties, and 
should never be used in medicine. There is reason to believe that 
many of the unfavorable symptoms which follow the use of bromide 
of ethyl occur only when the drug is impure or is improperly used. 

Physiological Action. — According to the studies of Thornton and 
Meixell in the author's laboratory at the Jefferson Medical College, 
the dominant action of the bromide of ethyl is on the respiratory, not on 
the circulatory system. This effect is depressant, but this influence is 
only met with after excessive doses. The blood-pressure falls under its 
influence to a slight degree, and the pulse is slowed through an influ- 
ence probably exercised on the inhibitory nervous mechanism of the 
heart. 

Therapeutics. — Bromide of ethyl is a useful anaesthetic for short 
operations, such as opening boils or abscesses, or for the relief of the 
pain in other brief surgical procedures. Originally introduced into 
general use in this country by Levis, it has been found unsuited to 
major surgical cases, because if continued for a long time it seriously 
depresses the respiration. Bromide of ethyl has been found of the 
greatest value by Montgomery, of Philadelphia, as an anaesthetic in 
labor and for minor gynecological operations in office practice. He 
finds that the patient may be allowed to inhale the drug from a Haw- 
ley inhaler, for as soon as she has had enough to produce anaesthesia 
the inhaler drops from her hand. The patient is also more obedient 
to the physician's directions, because of the fleeting influence of the 
drug, than when chloroform or ether is taken, and post-partum hemor- 
rhage through uterine relaxation is not so apt to occur. 



ETHYL CHLORIDE. 277 

A very great advantage possessed by bromide of ethyl is the rapidity 
of its action. A few whiffs are generally all that is needed to cause 
anaesthesia. It rarely produces disagreeable effects. Cases of sudden 
death under its use are, however, on record, and in some instances 
nervous twitchings, and even tetanic spasms, have been known to 
accompany its employment. These tetanic symptoms are, however, 
fleeting and generally of little importance. Nausea and vomiting 
rarely follow its use, but it is apt to leave an unpleasant garlic-like 
taste in the mouth, and a similar odor of the breath is frequently 
noted for several days after its use. 

Administration. — Bromide of ethyl should be administered for but 
a brief period, but when taken should be inhaled freely. It cannot 
be given carelessly with good effect. If a good sample is employed, 
45 minims to 3 drachms (3.0-12.0) is a sufficient amount to induce 
anaesthesia. This quantity should be used at once, instead of added to 
the inhaler drop by drop, as in the case of chloroform, and the cloth or 
inhaler should be held close to the mouth and nose, instead of at a 
little distance, as is often necessary with other anaesthetics. 

ETHYL CHLORIDE. 

Ethyl chloride (Mihylis Chlorichnn, U. S. and B. P.) is a haloid 
derivative (monochlor-ethane, C2H5CI), prepared by the action of 
hydrochloric acid gas upon absolute ethyl alcohol. 

On account of its extreme volatility, it should be preserved in her- 
metically sealed glass tubes, and kept in a cool place, remote from 
lights or fire. It is a colorless, mobile, very volatile liquid, having a 
characteristic, rather agreeable odor, and a burning taste. Ethyl 
chloride is slightly soluble in water and is readily soluble in alcohol. 
It boils at a temperature of 12.5° to 13° C. (54.5° to 55.4° F.), and at 
its ignition temperature burns with a smoky, green-edged flame, with 
the production of gaseous hydrochloric acid. When liberated, at 
ordinary room-temperatures, from its sealed glass tube, ethyl chloride 
vaporizes at once. The gas is very inflammable, and consequently it 
should not be used in proximity to a gas-flame or fire. If 1 mil. of ethyl 
chloride, while cold, be mixed with 20 mils, of alcohol, and a few drops 
of silver nitrate solution be added, no turbidity should be produced 
(absence of hydrochloric acid). It is constantly used in the form of a 
spray, as is methyl chloride, for the purpose of producing anaesthesia by 
freezing that part of the body with which it is brought into contact. 

Physiological Action. — Careful investigations show that ethyl 
chloride is a direct depressant to the heart muscle, but by no means so 
powerful in this influence as is chloroform. In other words, the differ- 
ence is a variation in degree and not in kind. Chloroform is nineteen 
times as powerful in this respect. So, too, ethyl chloride may cause a 
fall of blood-pressure, aside from its depressant effect upon the heart, by 
relaxing the bloodvessel walls, but to a far less degree than chloroform. 
It also decreases cardiac activity by stimulation of vagus centres in the 



278 



DRUGS. 



medulla and not by any reflex irritation. Ethyl chloride depresses the 
respiratory centre partly by its direct influence and partly by the fall of 
blood-pressure, whereby this centre is deprived of blood. When used 
for anaesthetic purposes these effects are all very moderate and only be- 
come important if cardiovascular disease is present. 

Therapeutics.— Ethyl chloride is used not only as a local anaesthetic 
by virtue of its freezing properties, but also by inhalation. It is 
necessary when it is given by inhalation, because of its great volatility, 
that it should reach the patient in concentrated form, and not have an 
opportunity to be dissipated into the surrounding air without first enter- 
ing the lungs. For this reason it should be used by the aid of a mask 
such as that employed in the administration of nitrous oxide gas. 
The mask should be applied in such a way as to cover tightly the 
nose and mouth, and the ethyl chloride is then projected on to a 
compress which is placed inside of it. Where it is impossible to 
obtain an inhaler made for this purpose, a tin or 
Fig. 48. glass funnel may be used as a substitute. The large 

end of this may be placed over the mouth and nose, 
the neck of the funnel containing loose absorbent 
cotton. Through the small end of the funnel the 




4Q 



305 



20 




Fig. 49. 



The cap unscrews and 
the drug escapes as a fine 
spray through a small 
hole in the end of the 
glass. 




Showing use of a glass funnel as an inhaler for ethyl chloride. 



chloride of ethyl is sprayed upon the cotton. By the careful adapta- 
tion of the hands to the sides of the funnel and the cheeks it is pos- 
sible to make this a very close inhaler. 



ETHYLHYDROCUPREIN HYDROCHLORIDE. 279 

A good way to keep ethyl chloride is in the form of a graduated 
glass container, so constructed that the drug is measured as the spray 
is forced from it by the heat of the hand. The drug is placed upon the 
market for this purpose in graduated glass containers. 

Anaesthesia produced by this method usually develops within fifteen 
to twenty seconds, and it is claimed that there are very slight changes in 
the pulse and respiration under its influence — 1 or 2 drachms (4.0- 
8.0) of ethyl chloride are usually sufficient to produce an anaesthesia 
lasting from five to ten minutes. Larger amounts than this may be 
employed when a longer anaesthesia is desired. It is a noteworthy 
fact that the pupillary and corneal reflexes are not lost under its in- 
fluence except in children, and that this drug cannot be used as an 
anaesthetic when muscular relaxation is indispensable. After the 
mask is removed the patient rapidly recovers consciousness and often 
experiences no unpleasant symptoms, although vomiting may occur 
in some cases. It is, so far as is yet determined, a fairly safe anaesthetic, 
but it must be used with care. The death-rate under its use is below 
that of chloroform. In 2550 cases recorded by Lotheisen 1 death 
occurred under its effects, but this may have been due to organic disease 
of the coronary arteries, which was present. Seitz has collected 1600 
cases with 1 death due to disease of the coronary arteries. Miller has 
collected 43,796 cases with 5 deaths, or 1 in 8759 anaesthesias. 

Ethyl chloride is often used to produce primary anaesthesia before 
giving ether or chloroform. (See Chloroform.) 

Chloride of ethyl is contraindicated if there is any obstruction in 
the air-passages, upper or lower. Serious valvular disease of the heart 
or myocardial degeneration also contraindicate it, and ether is probably 
safer under these conditions. If cyanosis develops during its use the 
drug must be withdrawn at once. It is noteworthy that alarming 
symptoms when they occur develop with great rapidity. 

The dose varies from 2 to 3 mils, in a child to 4 or 5 mils, for a man. 
The drug should not be pushed too freely at first and the patient should 
not be deprived of air, except early in the use of the drug. Telford 
and Falconer have shown that ethyl chloride may cause post-anaesthetic 
toxaemia. (See Chloroform.) 

ETHYLHYDROCUPREIN HYDROCHLORIDE. 

Ethylhydrocuprein hydrochloride (trade name "Optochin") is 
without doubt an efficient destroyer of the pneumococcus not only 
in vitro but in vivo. The recognition of the fact that croupous pneu- 
monia is a general infection, with the chief lesion in the lungs, makes it 
a drug of promise and statistics indicate that if fairly full doses are 
used early it diminishes mortality from this disease. After the exudate 
is well formed in the lung it does not materially hurry resolution and 
the pneumococci in the exudate are protected from the drug. The 
greatest objection to its use in efficient doses is that it has so great a 



280 DRUGS. 

toxic effect upon the optic nerve and retina that it may produce not 
only temporary amblyopia but permanent blindness. Doses of 7 
grains (0.5) three to four times a day exercise a bactericidal effect in 
the blood, but these doses approximate those which may produce toxic 
effects. The daily amount by the mouth should not be in excess of 
25 grains (1.6). Smaller doses may be used with safety to help the 
body destroy the coccus. It may be given in solution; or in capsule 
if followed by plenty of water, as it is prone to irritate the stomach. 
In the strength of only \ grain (0.03) to the pint of a 1 to 1500 solu- 
lion of thymol it is efficient in pneumococcus sore throat when used 
as a gargle, but it is very bitter. 



ETHYL IODIDE. 

Ethyl iodide {Mihylis Iodidum) is a colorless, non-inflammable 
liquid, which should be called hydriodic ethyl. Ethyl iodide must 
be kept in dark-colored bottles in a dark place to prevent it from 
undergoing decomposition. It is very volatile, and the fumes arising 
from it are slightly pungent, but not irritating in ordinary amounts. 
Unfortunately, the odor is disagreeable to most persons. 

Physiological Action.— Very little is known of the general physio- 
logical action of iodide of ethyl, and the drug would be a good one for 
laboratory investigation. It does not produce anaesthesia except in 
very large amounts. 

Therapeutics. — Iodide of ethyl is used in medicine entirely by inhala- 
tion for the treatment of subacute or chronic catarrh of the air-passages 
and for the purpose of rapidly impressing the system with iodine for 
alterative purposes, for it is the iodine in the remedy which produces 
the curative effects desired. In catarrhal states of the bronchial 
tubes the stimulating effect of the iodine is supposed to cause free 
secretion and to prevent abnormal thickening of the mucus and dilata- 
tion of the air-passages. For this reason iodide of ethyl is supposed 
to be of service in asthma and its resulting emphysema. Bartholow 
recommended this drug in the treatment of pneumonia. It was said by 
that writer to be particularly useful in the later stages of this disease, 
to aid in producing resolution, but the author has never seen it pro- 
duce much effect. (See Inhalations.) 

Administration. — 10 to 20 minims (0.65-1.3) may be placed upon 
a handkerchief and inhaled, or a small vial filled with the drug may 
be held in the hand under the nostrils. Under these circumstances 
the heat of the hand sets free the necessary amount of vapor. 

EUCAINE HYDROCHLORIDE AND LACTATE. 

Beta-eucaine hydrochloride (Beta-eucaince hydrochloridum, U. S.) 
is a synthetic substance having a chemical formula closely resembling 
that of cocaine. The drug is now marketed as a substitute for cocaine, 



EUCALYPTUS. 281 

it being claimed that it does not affect the heart as does the latter drug. 
Eucaine does not cause a primary contraction of the bloodvessels 
when locally applied, as does cocaine, but a hyperaemia of the parts 
affected. Two forms of eucaine have been used, eucaine "A" and 
eucaine "B;" but the latter is now exclusively employed for local 
anaesthesia, and for use in ophthalmic and genito-urinary surgery. 
A solution of eucaine can be sterilized by boiling without impairing 
its properties. Used by the process for producing infiltration anaes- 
thesia (see Cocaine), eucaine causes considerable pain before acting 
as an anaesthetic. For infiltration it should be used dissolved in 
the following formula and warmed before being injected: 

1$ — Eucainse hydrochloridi /3 gr. j (0.06). 

Sodii chloridi gr. x (0.60) . 

Aquae destillatae fgiij (90.0). 

In ophthalmic practice it is employed in 2 per cent, solution, and to 
ordinary mucous membranes in 5 per cent, solution — that is, 25 grains 
(1.6) to the ounce (30.0) of water. One advantage of eucaine is that 
it forms a permanent solution with water in 3.5 per cent, strength. 

Beta-eucaine lactate {Benzamine lactas, B. P.) has been intro- 
duced to take the place of the hydrochloride, as it is very much more 
soluble. 

Eucaine hydrochloride possesses a distinct disadvantage in its 
inability to cause primary contraction of the bloodvessels when 
locally applied, and this effect of cocaine is often most valuable to 
overcome local engorgement. Further, it causes severe smarting 
pain when dropped into the eye. 

Eucaine is capable of producing systemic effects resembling those 
due to overdoses of cocaine, and these must be treated by the use of 
strong coffee, alcohol, digitalis, and strychnine. If the case is urgent, 
ether and ammonia may be used as rapidly acting stimulants. 

EUCALYPTUS. 

Eucalyptus, U. S., is the leaves of Eucalyptus globulus, or blue- 
gum tree, a native of Australia, but grown at present all over the world. 
Its chief medicinal constituent is the oil of eucalyptus {Oleum Eucalypti, 
U. S. and B. P.), from which is derived Eucalyptol, U. S., which is a 
colorless liquid, obtained by distillation, having a characteristic, 
aromatic, and distinctly camphoraceous odor, and a pungent, spicy 
and cooling taste. The oil of eucalyptus and eucalyptol are used for 
the same purposes, but the latter is the refined product of the former. 

Physiological Action. — Locally applied, the oil is a decided irritant. 
10 to 20 minims (0.6-1.3) taken internally cause slight stimulation, 
followed by a sense of calm; while larger doses produce disturbed diges- 
tion and loose stools of oily odor. The pulse is increased in frequency 
and force, and intense headache may come on. After very large 



282 • DRUGS. 

doses there is a fall in pulse-force, bodily temperature, and strength 
of limb, and the respirations are decreased. A peculiar loss of sen- 
sation in the lower limbs may occur. If death takes place, it is due 
to respiratory failure. The drug is eliminated by the skin, kidneys, 
bowels, and lungs. The urine may have the odor of violets, as it 
sometimes does after the use of oil of turpentine. 

The oil of eucalyptus has considerable antiseptic power. 

Therapeutics. — Eucalyptus is used in malarial fever where quinine 
cannot be had nor be borne by the patient owing to idiosyncrasy. In 
bronchitis, in an emulsion or in capsule, it is of great value in the later 
stages (see Bronchitis), since in its elimination by the lungs it acts 
locally upon the inflamed mucous membrane. It may be used in the 
subacute forms of gonorrhoea for the same effects, The following pre- 
scription will answer: 

1^ — Olei eucalypti r f oj (4.0). 

Olei amygdalae expressi f 5j (4.0). — M. 

Pone in capsulas No. x. 
S. — One t. i. d. after meals. 

Oil of eucalyptus is very useful in some forms of rheumatic headache 
and in headache dependent upon malarial fever. 

Eucalyptol, U. S., is obtained from oil of eucalyptus, and is largely 
employed by rhinologists and others in lotions and other nasal appli- 
cations. It may be used in solutions of fatty oils, but is insoluble in 
water, although it is soluble in alcohol and ether. 

Administration.— The fluidextract {Fluidextr actum Eucalypti, U. S.) 
is given in the dose of 10 minims (0.6) to 2 drachms (8.0), the oil 
(Oleum Eucalypti, U. S. and B. P.) in the dose of 5 minims (0.3), \ to 
3 minims (0.03-0.18), B. P. The dose of eucalyptol is 5 minims (0.3) 
in capsule. 

Trochiscus Kino Eucalypti and Unguentum Eucalypti are official 
in the B. P., but are seldom used. 

EUDOXINE. 

Eudoxine is the bismuth salt of nosophen. (See Nosophen.) It 
occurs as an odorless, tasteless, insoluble, reddish-brown powder, 
containing less than 60 per cent, of iodine. Eudoxine is employed in 
medicine as an intestinal antiseptic and antifermentative. It is used 
in the diarrheas of children in the dose of § to 5 grains (0.03-0.3), 
and given to adults for the same purpose in the dose of 5 to 20 grains 
(0.3-1.3). The range of usefulness of this drug is much the same as 
bismuth in such cases, except that it is less astringent, but more 
antiseptic and alterative. Because of the latter influence it is indi- 
cated in subacute dironic catarrhal inflammation of the bowels with 
diarrhea. 



EUPHORBIA PILULIFERA. 283 



EUONYMUS. 



Euonymi Cortex, B. P., or Wahoo, is the dried bark of Euonymus 
atropurpurea, a native plant of the United States. It contains an 
active principle, Euonymin, B. P. As a laxative its action is very 
slow and mild; it is thought to act particularly on the liver and may 
be used when moderate hepatic torpor is present. 

Administration. — The dose of the solid extract {Extr actum Euonymi, 
is 3 to 10 grains (0.2-0.6), of the fluidextract, the dose is 1 to 2 
fluidrachms (4.0-8.0). Of euonymin the dose is \ to 1 grain (0,03- 
0.06). 

EUPATORIUM. 

Eupatorium, Thoroughwort, or Boneset is the dried leaves and 
flowering tops of Eupatorium perfoliatum, an American plant which 
is largely used as a simple bitter tonic and diaphoretic in household 
medicine. The drug is generally given in hot infusion in cases of 
arrested menstruation due to cold or in the chill of a remittent or inter- 
mittent fever, and also for anorexia and debility. Its taste is very 
disagreeable. In the dose of a pint (480 mils.) of the cold infusion it 
has been used as an emetic. The fluidextract is given in the dose 
of 30 minims to 1 drachm (2.0-4.0). 

EUPHORBIA PILULIFERA. 

This herb is sometimes called snake-weed or cat's hair, and is a 
native of Australia and the West Indies, where, like stramonium, it 
grows profusely as a weed by the roadside. 

Physiological Action. — In toric doses the drug kills small animals 
by failure of the respiration and circulation, these two vital functions 
being greatly affected by doses which exert no great influence on the 
rest of the body. . In full dose it may cause some gastric irritation. 

Therapeutics. — Euphorbia pilulifera is one of the remedies intro- 
duced into medicine for the relief and cure of asthma, in which 
disease the results obtained, after other remedies fail, are very extra- 
ordinary if the reports of those who have given it a thorough trial 
can be accepted without reserve. As yet we do not know the form 
of asthma which is most relieved by its use, and its employment is 
purely empirical. It has also been highly praised in the treatment of 
chronic bronchitis and emphysema. 

Administration. — Euphorbia pilulifera is best given in the form of 
the fluidextract in the dose of 30 minims to 1 drachm (2.0-4.0). The 
decoction is made by adding a "handful of stalks with the leaves on 
them to 2 quarts (2 litres) of boiling water, and boiling down to 1\ 
quarts (1J litres)." Of this decoction the dose is a small wineglass- 
ful (60.0) three times a day. (See Asthma.) 



284 DRUGS. 



EUPHTHALMIN. 

Euphthalmin is a synthetic alkaloid used as an active mydriatic. 
It possesses an effect upon the general system very like that of atro- 
pine, but when first dropped into the eye may cause slight salivation 
through irritation of the secretory fibres of the chorda tvmpani which 
it reaches after absorption. The pupil under its influence begins to 
dilate in from fifteen to twenty minutes after a few drops of a 2 to 10 
per cent, solution are instilled. The maximum dilatation is reached 
in about an hour, and disappears in about five to eight hours. Vinci 
states that the mydriasis is due to paralysis of the oculomotor nerve- 
endings, and that the sympathetic is not affected. 



EUQUININE. 

Euquinine, or quinine sethyl carbonate, occurs as delicate white 
needles, which are tasteless. It is slightly soluble in water, but readily 
so in alcohol, ether, and chloroform. When placed in acid mixtures it 
becomes bitter. Euquinine is used as a substitute for quinine, particu- 
larly for children, who dislike the bitter taste of the older drug and 
cannot take pills or capsules. 



EUROPHEN. 

Europhen is the result of the action of iodine on isobutylortho- 
cresol, in the presence of an alkali, and appears as a fine yellow powder, 
soluble in alcohol, ether, chloroform, and oils, but insoluble in water. 
It was introduced because it was hoped that it might prove a useful 
substitute for iodoform. One advantage claimed for it is that it 
parts with its iodine very slowly, and so is not apt to produce toxic 
symptoms as rapidly as does iodoform. For this reason, however, it 
lacks the remedial power of the older drug, except in those instances 
in which a drying power is needed which will keep the wound pure 
by making it too dry to be favorable to the growth of germs. When 
such an action is desired, europhen possesses the additional advantage 
of being five times as bulky as iodoform. In the treatment of tuber- 
culous lesions europhen has proved itself very inferior to iodoform. 
Owing to its stability, it fails to part with its iodine except in the 
presence of moisture, and is useless in dry skin diseases. It nas been 
found useful in scrofuloderm, ulcer of the legs, and lupus. Europhen 
may be employed in a salve of the strength of from 5 to 10 per cent., 
or with olive oil or lanolin. It can also be added to flexible collodion. 
The drug does not possess the odor of iodoform, but experience 
will probably prove it to be more irritating than the latter drug. The 



FLAXSEED. 285 

internal dose is 1 to 3 grains (0.06-0.2) in cases of syphilis. Europhen 
is incompatible with metallic oxides and the preparations of mercury, 
and also with the starch and zinc paste largely used by dermatologists. 



EXALGINE. 

This substance is really methyl-acetanilide, and closely resembles 
acetanilide or antifebrin in its effects. It is given for the same purposes 
as are acetanilide and antipyrine — namely, for the relief of pain in loco- 
motor ataxia and other nervous affections — but never as an antipyretic 
When used, exalgine should be given night and morning as a rule, so 
that the doses shall not be near together. The beginning dose should 
be from 2 to 4 grains (0.12-0.25), and not more than 15 grains (1.0) 
should be given in twenty-four hours. It is stated by those who have 
used the drug that fever contraindicates its employment. 

The following prescriptions will be found applicable: 

Ifc— Exalgini .-...'. gr. xxx (2.0). 

Tincturae aurantii dulcis .... f3ij (8.0). — M. 
Fiat solutio et adde 

Syrupi aurantii f oss (16.0). 

Aquae menthae 'piperita*. . q. s. ad f§iv (120.0). — M. 
S. — A tablespoonful night and morning. 



Or, 



1^— Exalgini ' . . . gr. xxx (2.0). 

Spiritus frumenti fgss (16.0). — M. 

Fiat solutio et adde 

Syrupi fSj (30.0). 

Aquae destillatao . . . . q. s. ad fgiv (120.0).— M. 
S. — Tablespoonful night and morning. 



FLAXSEED. 

Flaxseed or linseed (Linum, U. S. and B. P.) is the seed of Linum 
usitatissimum, or flax from which linen is made; it is official in the 
B. P. as Lini Semina. These seeds contain an oil and a mucilage, 
the first of which is largely used in the arts, and the second is some- 
times employed in medicine. The oil (Oleum Lini, U. S. and B. P.) 
is also used by physicians and pharmacists for various purposes. 

Therapeutics. — Flaxseed acts as a demulcent to inflamed mucous 
membranes, and is used largely in the treatment of acute cystitis, 
bronchitis, gastritis, nephritis, and similar states, in the form of flax- 
seed tea. This is prepared by mixing together 3 drachms (12.0) of 
flaxseed, not ground, 30 grains (2.0) of extract of liquorice, 10 ounces 
(300.0) of boiling water, and allowing the mixture to stand one to 
four hours in a warm place. If the mixture is boiled, the oil is set 



286 DRUGS. 

free and makes the dose disagreeable. This infusion may now be 
made more tasteful and useful by the addition of a little lemon-juice 
and sugar and by the placing of from 1 to 2 drachms (4.0-8.0) of gum 
arabic in the pitcher containing it. If the cough is excessive, a little 
paregoric may be added. Linseed oil is used sometimes as a laxative 
in the dose of 2 ounces (60.0), and is said to be of service when so 
given in the treatment of hemorrhoids. 

Flaxseed meal (Lini Farina) when moistened is employed uni- 
versally as a useful poultice. 

Under the name of Carron oil (Linimentum Galcis, U. S.) an 
emulsion of lime-water and linseed oil, equal parts, is a standard 
application for limited or extensive burns. 



FORMIDINE. 

Formidine is a condensation product of iodine, formaldehyde, and 
salicylic acid, and is a true chemical compound. It appears as a 
reddish-yellow powder which is practically tasteless, but possesses a 
slight odor of iodine. It is insoluble in water, dilute acids, alcohol, and 
most ordinary solvents, but is slowly soluble in alkaline solutions. 
Brought in contact with the juices of the tissues, it slowly dissolves and 
separates into its constituent bodies. 

Formidine is used externally as a dusting-powder for wounds, or, 
in other words, as a substitute for iodoform, as it possesses no dis- 
agreeable odor, is non-irritating, and strongly antiseptic. If may be 
applied either in dusting-powder, ointment, suspended in oils, or upon 
bandages, or it may be diluted with the various dusting-powders, such as 
talc, oleate of zinc, or bismuth. 

Internally it may be given as an intestinal antiseptic, as it is not dis- 
solved in the stomach. The best method of administration is to give it 
stirred up in water, milk, coffee, or chocolate. The dose is 5 to 10 
grains (0.3-0.6). Large doses, given to animals, seem to prove that 
it does not produce toxic symptoms. 

FORMIC ALDEHYDE (FORMALDEHYDE). 

Formic aldehyde is a gaseous body difficult of application because 
of its physical characteristics, but nevertheless possessing very great 
power as a disinfectant or germicide. It is prepared by subjecting 
methyl alcohol to oxidation, and almost every instrument-maker has a 
device whereby this gas may be generated, and the rooin formerly occu- 
pied by a sick person thereby disinfected far more efficaciously than can 
be accomplished by burning sulphur. The doors and windows of the 
room should be tightly shut during the process of disinfection and for 
several hours after the formaldehyde generator is exhausted. As the 



FORMIC ALDEHYDE. 287 

gas is exceedingly irritating to the eyes and respiratory passages, no one 
should attempt to enter the room. The moistening of fabrics aids 
the gas in destroying germs. After the disinfection is completed 
the room should be aired for many hours, or, if it must be used soon, 
it may be rendered capable of habitation by spraying a 20 per cent, 
solution of ammonia to neutralize the acid atmosphere. The great 
advantage of formaldehyde for disinfectant purposes is the fact that 
it permeates every nook and cranny, and yet does no injury to col- 
ored fabrics, as does chlorine gas under similar circumstances. 
The safety, efficiency, and cheapness of formaldehyde gas as a dis- 
infectant, and of the solution, render this agent a most valuable one. 
(See Disinfection.) 

Liquor Formaldehydi, U. S. and B. P., is an aqueous solution of 
formaldehyde which contains 37 per cent., by weight, of the gas. 
It forms a clear, colorless liquid of a pungent odor, which is exceedingly 
irritating to mucous membranes. It can be mixed with water and 
alcohol in all proportions, but on standing its solution becomes milky 
because of the separation of paraformaldehyde. It should be kept in 
a cool place protected from light. 

This official solution of formic aldehyde, in the strength of 37 per 
cent., has been widely used of late for disinfectant and antiseptic pur- 
poses. For all these purposes it is usually diluted still further by the 
addition of water. A 1 per cent, solution is usually quite active enough 
for surgical antisepsis, and is far less poisonous than is the bichloride 
of mercury. A similar percentage, or a little stronger, may be used 
to preserve pathological specimens, and in the proportion of 1 to 
32,000 it will preserve milk for several days. Taken internally, in 
small amounts well diluted, it does not possess any toxic properties, but 
if its quantity is large or it is in concentrated form it acts as an intense 
respiratory and gastric irritant. The chemical antidote is ammonia 
water, or the aromatic spirit of ammonia, well diluted with pure 
water. 

Concentrated undiluted formaldehyde solution may be used for the 
purpose of cauterizing syphilitic sores, and it is the specific treatment 
for the bites of rabid animals. 

Formaldehyde is useful when locally applied to check excessive fetid 
sweating, by virtue of its antiseptic effect and because it hardens and 
contracts the skin. The solution used may be made by diluting the 37 
per cent, commercial solution with 4 to 6 parts of water, or using " Eufor- 
mol " diluted or pure as a lotion. Euformol contains eucalyptus, gaul- 
theria, menthol, boric acid, and formaldehyde, and is pleasanter to use 
than the crude preparation. Diluted in the proportion of 1 to 6 of water 
it may be employed as a lotion to the entire body to check colliquative 
sweats. 

One teaspoonful (4.0) of the official solution placed in 3 ounces (90.0) 
of sweetened water is a most excellent solution with which to kill flies, 
who greedily take it and speedily die. 



288 DRUGS. 

Numerous cases of poisoning by the accidental or suicidal ingestion 
of formaldehyde solution have been recorded. The symptoms consist 
in epigastric pain which soon becomes diffused and which is usually 
immediate and severe in onset, accompanied by repeated vomiting 
of blood-stained mucus. Sometimes unconsciousness comes on almost 
at once and often lasts for many hours, the symptoms resembling those 
of apoplexy. The suddenness of onset depends chiefly upon whether 
the stomach is empty. When it is full of food or liquid, the symptoms 
do not develop so rapidly. There seems to be no doubt that the inges- 
tion of a large dose may produce death within a very few minutes in 
rare cases. Intense inflammation of the uvula, pharynx, gullet, and 
stomach develops, and at autopsy these parts are often found eroded and 
leather-like in character. Fatal results in adults have followed the 
ingestion of 3 ounces of the ordinary formaldehyde solution. The smell 
of the vomit is diagnostic. The chemical antidote is ammonia water, 
well diluted, or any one of the ammonium salts, well diluted, such as 
ammonium acetate. The stomach should then be washed out, and 
soothing drinks, such as sweet oil and starch-water, given with morphine 
hypodermically for the relief of pain. 

Under the name of "Glutol" a compound of formaldehyde and 
gelatin is used as an antiseptic powder, which, drying the surface of 
the wound or ulcer, seals it and renders it sterile. It is claimed to be 
a particularly efficient dressing for burns. 

GALLIC ACID. 

Acidum Gallicum (U. S. and B. P.) is usually prepared from tannic 
acid. It occurs in nearly colorless, long, needle-like crystals, which 
are soluble in 87 parts of cold water at 25° C. (77° F.), 4.6 parts 
of alcohol, and 3 parts of boiling water. 

Physiological Action. — Gallic acid is an astringent, but not a coag- 
ulator of blood. Locally applied in bleeding, it is useless, but given 
internally in hemorrhages which cannot be acted upon by the direct 
local application of tannic acid, it is thought to be useful as a haemo- 
static because it contracts the bloodvessels. This is very doubtful. It 
is eliminated from the body by the kidneys as gallic acid. 

Therapeutics. — Gallic acid may be used with some success in hcema- 
turia, hemoptysis, colliquative sweats, and in chronic bronchitis with 
profuse expectoration. 

Combined with opium, it is one of the best remedies in diabetes 
insipidus, and is also useful in diabetes mellitus. 

In albuminuria dependent upon a relaxed, atonic state of the kidneys 
and in acute or chronic diarrhoea gallic acid may be used with advan- 
tage. In the form of the ointment it is useful in the treatment of 
psoriasis, and in the cure of ulcers and sores which are actively dis- 
charging. A very useful application to external hemorrhoids is equal 
parts of stramonium ointment and gallic acid. 



GAMBIR. . 289 

Administration. — Gallic acid is given in the dose of 2 to 40 grains 
(0.12-2.6) in pill or solution. It ought never to be used with any salt 
of iron, as it is chemically incompatible. The preparation used locally 
is Unguentum Acidi Gallici. 

Nut-gall. 

Nut-galls (Galla, U. S. and B. P.) are the small excrescences found 
upon the oak (Quercus infectoria) formed by the ova of the fly Cynips 
tinctoria. Their sole value depends upon the tannic acid contained 
in them. The ointment (Unguentum Gallce, U. S. and B. P.) and 
Unguentum Gallce cum Opii, B. P., are used as astringent and sedative 
applications. 

GAMBIR. 

Gambir, U. S., is an extract derived from the leaves and young shoots 
of Ouronparia gambier. It takes the place heretofore held by catechu. 
Gambir depends for its medicinal value upon the astringent properties 
which it possesses. Beyond this power it has no particular value. 

It is of a dark-red color, has a somewhat sweetish taste, and is insol- 
uble, like most extracts, in water. 

Therapeutics. — Like all the vegetable astringents, gambir is used as 
a remedy for diarrhoea, particularly that of the serous type or that in 
which the stools are of too fluid a consistence. If large amounts of 
mucus in the passages show a catarrhal state of the bowel, the mucus 
should be displaced by a purge of castor oil or sulphate of magnesium 
before the astringent is used. 

Gambir may or may not be combined with opium in cases of diar- 
rhoea, and the following prescription will be found of service in many 
instances : 

For an adult: 

$ — Tincturse gambir composite f §ij (60.0). 

Tincturse opii camphoratse f§ij (60.0). 

Misturse cretse f §ij (60.0).— M . 

S. — Dessertspoonful (8.0) every four hours till relieved. To be shaken before 
using. 

In cases of sere throat where the secretion is excessive and the inflam- 
mation subacute, gambir may be used as a gargle. 

In cases of spongy gvms gambir is sometimes useful as a mouth- 
wash. If the powdered gambir is used internally, the dose is 20 to 
30 grains (1.3-2.0). The dose of the compound tincture of gambir 
(Tinctura Gambir Composita, U. S.) is 1 to 2 fluidrachms (4.0-8.0). 
Its only constituent besides the gambir is cinnamon. The troches of 
gambir ( Trochisci Gambir, U. S.) are employed in sore throat, and are 
to be held in the mouth. They are not generally used. 

In the B. P. gambir is still official as catechu and the following 
19 



290 DRUGS. 

preparations are also official: Trochiscus Catechu; the tincture (Tine- 
turn Catechu), dose J to 1 fluidrachm (2,0-4.0); and a compound 
powder (Pubis Catechu Compositus), composed of catechu, kino, and 
rhatany, the dose of which is 10 to 40 grains (0.6-2.6). 

GAULTHERIA. 

Wintergreen, or Gaultheria procumbens, is an American evergreen 
containing a volatile oil. The oil possesses a peculiar, exceedingly 
penetrating odor and a warm aromatic taste. It is about 96 per cent, 
salicylate of methyl. The Salicylate of Methyl (Methylis Salicylas, 
U. S.) is derived from the oil or as an artificial product. 

Physiological Action. — Owing to the large amount of salicylate ol 
methyl contained in the oil, its physiological action is almost identical 
with that of salicylic acid. (See Salicylic Acid.) 

Therapeutics. — Aside from its use as a flavoring substance, oil of 
gaultheria may be used .in place of the ordinary salicylates in all forms 
of rheumatism in which they are useful. This oil is best given in cap- 
sules or emulsion or dropped on a teaspoonful of sugar three times a 
day after meals. The dose may be as high as 100 minims (6.6) a day, 
but if 60 minims (4.0) three times a day are without effect, pushing 
it further is useless. Very few patients can take more than 30 minims 
a day without suffering from a disordered stomach. 

Lannois and Limousin have highly recommended the application 
of this oil to acute and chronic rheumatic joints. The oil is placed 
on lint, and then the lint is wrapped around the part affected, 
evaporation being prevented by applying a gutta-percha covering. 
They assert that this treatment gives rapid relief, although they admit 
that after it the skin may desquamate. 

GELSEMIUM. 

Gelsemium, U. S., and Gelsemii Radix, B. P., or yellow jasmine, 
as used in medicine is the dried rhizome and roots of Gelsemium 
sempervirens, a climbing plant of the Southern United States. It 
contains two alkaloids, gelsemine and gelseminine. 

Physiological Action. Nervous System. — Gelsemium paralyzes the 
spinal cord, particularly on its sensory side(?), although the motor 
side is certainly ultimately depressed. It does not influence the nerves 
or muscles except those of the head, on which it acts as a paralyzant, 
particularly affecting the motor fibres. 

Circulation. — Gelsemium is a depressant to the circulation, act- 
ing particularly on the heart. It paralyzes the vagus and lowers blood- 
pressure. 

Respiration. — Gelsemium kills by paralyzing the respiratory cen- 
tres (Sanderson, Ringer, and Murrell). 



GELSEMIUM. 291 

Temperature. — In overdose the drug lowers bodily heat very 
markedly. 

Eye. — Gelsemium is a mydriatic of considerable power, causing, 
when dropped into the eye, wide dilatation of the pupil, a result due 
to paralysis of the oculomotor nerve peripherally. 

Therapeutics. — Gelsemium is used in headache and migraine depend- 
ing on nervous troubles or upon eye-strain. It is particularly useful in 
combination with cannabis indica. (See Cannabis Indica and Migraine.) 

In malarial fever it is said to be of service, but this is doubtful. 
In the early stages of pneumonia and pleurisy as a substitute for aconite 
it has been highly spoken of by Bartholow. 

Gelsemium has also been found of value in asthma, whooping-cough, 
laryngismus stridulus, and nervous cough. In localized muscular 
spasm, such as is seen in torticollis or wryneck, and in spasmodic 
dysmenorrhea, it is of considerable service. It ought not to be used 
if the system is already depressed, but only in sthenic cases. 

When used as a mydriatic, Tweedy recommends gelsemine as equal 
to atropine in effect, but much moie transient in its influence. He uses 
8 grains of commercial gelsemine to the ounce (0.5-30.0) of water 
instilled, drop by drop, into the eye every fifteen minutes for one hour, 
and then every half-hour for two hours. 

Poisoning. — The most prominent symptoms of gelsemium poison- 
ing are ptosis and dropping of the jaw. These are preceded by a 
sensation of languor, a desire to lie down, relaxation, and muscular 
weakness. Gelsemium is apt to cause temporary internal squint, 
owing to its paralyzant action on the sixth pair of cranial nerves. 
The pulse becomes rapid and feeble, the skin wet and cold, the face 
pinched and anxious, the voice is lost, and death ensues from centric 
respiratory failure and an almost simultaneous cardiac arrest. Sen- 
sation in man is impaired very late in the poisoning. 

The treatment of the poisoning consists in the use of cardiac stimu- 
lants, such as ammonia and digitalis, the application of external heat, 
and the employment of atropine and strychnine for the purpose of 
stimulating the respiratory centre. Emetics and the stomach-pump 
are, of course, to be employed if the patient, is strong enough. 

Administration. — The fluidextract {Fluidextr actum Gelsemii, U. S.) 
is given in the dose of 2 to 5 minims (0.10-0.30) and the tincture 
{Tinctura Gelsemii, U. S. and B. P.) 5 to 15 minims (0.30-1.0). 
Extractum Gelsemii, U. S., is given in the dose of J grain (0.015). In 
some parts of the United States physicians largely employ a very strong 
unofficial tincture of gelsemium, the dose of which is 1 to 2 minims. 
Gelsemine and gelseminine should not be given internally. 



292 DRUGS 



GENTIAN. 



Gentiana, U. S., is the root of Gentiana lutea, or yellow gentian, 
a European plant. It contains gentianine and gentisic acid, and has 
a bitter taste. This drug is official in the B. P. as Gentiana? Radix. 

Therapeutics. — Gentian is one of the most efficacious bitter tonics 
that we possess. In the anorexia following acute diseases and in gout 
and malarial poisoning with dyspepsia it is of value. Combined with 
bicarbonate of sodium, it is of great service in the treatment of the 
subacute gastric and intestinal catarrh of children. 

Administration. — The compound tincture (Tinctura Gentiana Com- 
posite, U. S. and B. P.) is given in the dose of 1 to 2 drachms 
(4.0-8.0), | to 1 fluidrachm (2.0-4.0), B. P., the fluidextract (Fluidex- 
tractum Gentiana 1 , U. S.) in the dose of 30 minims to 1 drachm (2.0-4.0), 
and the solid extract (Extr actum Gentiana, U. S. and B. P.) in the dose 
of 1 to 8 grains (0.06-0.50). Infusum Gentiana? Compositum, B. P., 
is given in the dose of J to 1 fluidounce (15.0-30.0). The compound 
tincture and compound infusion are composed of gentian, bitter orange- 
peel, and cardamoms. The following prescription is an excellent one 
for use in convalescence from prolonged fevers : 

1$ — Acidi nitro-hydrochlorici diluti . . . . f oj i vel f 5 ij (4.0-8.0). 

Tincturse nucis vomicae f o j (4.0). 

Tincturse cardamomi compositse . . . f§ij (60.0). 
Tincturse gentianse compositse . q. s. ad f 5iv (120.0). — M. 
S. — Teaspoonful (4.0) in water after meals. 

GINGER. 

Zingiber, U. S. and B. P., in the rhizome of Zingiber officinale, a 
plant of Hindostan, Jamaica, and other tropical countries. Black 
ginger is the dried rhizome with its bark, while white ginger has this 
covering removed. It contains a hot volatile oil and an aromatic 
resin, and is largely used in domestic medicine as a carminative and 
stomachic. In the treatment of menstrual cramps it is often given, 
and is particularly useful in those cramps due to suppression from 
exposure to cold. Ginger is often combined with purgative medicine 
to prevent griping and for its pleasant flavor. It is decidedly consti- 
pating, and when used in diarrhoea mixtures is of value other than as 
a flavoring addition to the prescription, 

Administration. — The fluidextract (Fluidextr actum Zingiberis, U. S.) 
is given in the dose of 10 to 30 minims (0.60-2.0), well diluted; the 
tincture (Tinctura Zingiberis, U. S. and B. P.), dose 20 minims to 
2 drachms (1.3-8.0); the syrup (Syrupus Zingiberis, U. S. and B. P.), 
dose 30 minims to 2 drachms (2.0-8.0), J to 1 fluidrachm (2.0-4.0), 
B. P.; the oleoresin (Oleoresina Zingiberis, U. S.), dose \ to 1 minim 
(0.03-0.05), well diluted or in pill. The troches (Trochisci Zingiberis) 
are used as stimulants to salivary secretion. 



GLYCERIN 293 

GLANDULAR EXTRACTS. 

Within the past two decades physiological investigations have proved 
that several glands in the body pour out into the blood- or lymph-vessels 
ferments or substances which perform definite physiological functions 
in the system. Disease of these glands perverts these functions, and 
secondary disorders follow. Acting upon the discoveries just named, 
some persons have attempted to show that nearly all of the organs of 
the body, be they glands or not, possess these functions, until they 
have reached a reductio ad absurdum. On the other hand, some of 
the glands are now used, when derived from the lower animals, for 
definite therapeutic purposes, such as the thyroid gland and the supra- 
renal bodies, for example. The use of these glands will be found dis- 
cussed under their own names, but unimportant glands in therapy, or 
those in regard to which doubt exists, are included under the general 
heading here given. (See Thyroid Gland and Suprarenal Gland.) 

The employment of testicular juice, or the dried gland itself, has been 
practically abandoned, but the dried corpus luteum seems to possess 
considerable power. It has been used to combat the symptoms fol- 
lowing double oophorectomy and those common to the menopause, and 
also for aphrodisiac purposes. On the ground that chlorosis is due to a 
faulty internal secretion of the ovary, it has been given in this condi- 
tion with asserted good results, and also in osteomalacia, neurasthenia. 
and hysteria in females. The dose is from 2 to 4 grains (0.10-0.20) 
a day. (See Corpus Luteum.) 

The use of cerebral and spinal extracts has proved futile, as has 
also the use of bone-marrow, in pernicious an&mia. The pancreas 
has been used in pancreatic diabetes, but its value is in doubt. The 
liver has been given in the dose of 3 ounces (90.0) of fresh gland a 
day to combat the delirium of cirrhosis, with asserted good results 
(Carnot), and has been thought to do good in alcoholic cirrhosis with 
icterus, in that the hemorrhages were arrested, the delirium ceased, 
and the patient generally improved. The same treatment has been 
tried in diabetes. It is difficult to see how it can be of benefit. 

While glandular therapeutics gives promise of aiding greatly in 
the treatment of disease, and while for this reason the cautious phy- 
sician should not oppose resort to the use of glandular extracts, he 
should, nevertheless, always study the physiological function of the 
gland to be employed in order that he may reach a clear idea of its 
remedial possibilities. The extraordinary effects of some glands do 
not prove that all animal extracts are of value, nor does the failure of 
others indicate that all are useless. 



GLYCERIN. 

Glycerinum, U. S. and B. P., sometimes called glycerol, is a liquid 
obtained by the decomposition and distillation of fats. It is a clear, 



294 DRUGS 

colorless liquid, of a thick, syrupy consistence, smooth to the touch, 
odorless, sweet to the taste, which produces a sensation of warmth in 
the mouth. When exposed to the air, it absorbs moisture. It is soluble 
in all proportions in water and alcohol; also soluble in a mixture of 
3 parts of alcohol and 1 part of ether, but insoluble in ether, chloroform, 
carbon disulphide, petroleum benzin, benzene, and fixed and volatile oils. 
Glycerin is slowly volatilized from weak aqueous solutions, at or 
above 100° C. (212° F.), with the vapor of water. At boiling tem- 
peratures 70 per cent, to 100 per cent, glycerin rapidly volatilizes; 
95 per cent, glycerin boils at 165° C. (329° F.); anhydrous glycerin 
boils at 290° C. (554° F.) without decomposition. Under continued 
heat it is finally entirely decomposed and dissipated. 

An aqueous solution of glycerin is neutral to litmus paper. It 
possesses great power in absorbing water and of dissolving many 
substances. Even if pure it irritates the skin of susceptible persons 
when applied locally, by its absorption of water, and often causes a 
slight rash. 

Physiological Action. — Injected into the circulation in large amounts, 
glycerin causes convulsions, which are due to its hygroscopic power. 

According to the clinical researches of Pavy, glycerin increases the 
polyuria of diabetes almost one-half, and for this reason he thinks it is 
not to be employed in this class of cases as a substitute for sugar. Other 
clinicians, however, disagree with him and use it constantly for this 
purpose with asserted advantage. 

Therapeutics. — Glycerin may be employed as a sweetening agent 
in the food of diabetics and in cases where sugar cannot be used. It 
has also been given as a laxative in 1- or 2-drachm (4.0-8.0) doses by 
the mouth, and in enema — 1 to 4 drachms (4.0-16.0) with or without 
equal parts of water. In some cases it may be used in suppository in 
the official Suppositoria Glycerini, U. S. and B. P. This latter method 
is very successful in chronic constipation. Its continued use by sup- 
pository may, however, result in rectal irritation. 

As an antiseptic it is used for preserving specimens and for keeping 
alkaloids in solution for hypodermic use. 

In acute coryza, applied by a spray or brush to the nostrils, it is 
sometimes of service; for this purpose it should be diluted four or five 
times with water. If used on the skin, it should be diluted one-half 
with water. In cases of impacted cerumen in the external auditory 
canal glycerin is often of service in softening the mass. 

The uses of glycerin, other than those mentioned, are many. In the 
proportion of equal parts of glycerin and water it makes a very useful 
rnouth-wash for the sore and dry mouth of typhoid fever and for the 
removal of sordes. The same wash, with lemon-juice added to it, is very 
agreeable and will relieve the dry, glazed tongue of advanced phthisis. 
Owing to the fact that glycerin is hygroscopic, it may be used as a 
deplet-ant on a pledget of cotton in congestion of the uterine cervix, the 
tampon being renewed daily. 



GOLD 295 

For the prevention of bed-sores Ringer recommends the daily wash- 
ing and rubbing of the part likely to be affected, followed by the appli- 
cation of glycerin and water, with a draw-sheet placed smoothly against 
the patient to protect the bedding. 

Glycerin and whisky is a favorite household remedy for colds and 
coughs, but is not very useful. Glycerite of starch (Glyceritum Amyli, 
U. S.; Glycerinum Amyli, B. P.) is used as a protective over super- 
ficial irritations of the skin. Glycerite of yolk of egg (Glyceritum 
Vitelli) is used in making emulsions. 

A very useful ointment for the application of medicinal substances 
to the skin may be made by constantly mixing in the presence of heat 
1 part of potato starch and 15 parts of pure glycerin. The result is a 
clear, transparent, jelly-like substance which does not decompose, and 
has the advantage of holding the medicament which it carries in solu- 
tion rather than by mechanical suspension. 

The B. P. preparations of glycerin are as follows: Glycerinum 
Acidi Carbolici, Glycerinum Acidi Tannici, Glycerinum Aluminis, 
Glycerinum Acidi Borici, Glycerinum Plumbi Subacetatis, Glycerinum 
Tragacanthce, Glycerinum Boracis, Glycerinum Pepsini, Glycerinum 
Amyli, and Unguentum Glycerini Plumbi Subacetatis. 

GLYCERITE OF BOROGLYCERIN. 

The glycerite of boroglycerin (Glyceritum Boroglycerini, U. S.) is 
made by heating 460 Gm. of glycerin, in a tarred porcelain dish, to a 
temperature not exceeding 150° C. (302° F.), and adding the boric 
acid, 310 Gm., in portions, constantly stirring. When all is added 
and dissolved, continue the heat at the same temperature, frequently 
stirring, and breaking up the film which forms on the surface. When 
the mixture has been reduced to the weight of 500 Gm., add to it 
500 Gm. of glycerin, mix thoroughly, and transfer it to suitable vessels. 
It is soluble in water. 

Locally the glycerite of boroglycerin is used as an antiseptic and as a 
vehicle for phenol, chrysarobin, and the vegetable alkaloids in the 
treatment of skin diseases, and in diseases of the eye, such as purulent 
ophthalmia. It is also used on vaginal tampons to deplete the sur- 
rounding tissues. 

GOLD. 

Gold itself is not official in the U. S. P., but has been recommended 
very highly by Bartholow in chronic Bright' s disease in the form of 
the chloride of gold and sodium (Auri et Sodii Chloridum, U. S.). 
The dose of this substance is ^V to y 1 ^ grain (0.003-0.006) once, twice, 
or thrice a day. The author has not found it of any value. Gold 
has also been strongly recommended for indigestion with epigastric 
pain after eating when looseness of the bowels is present, and it is 



296 DRUGS 

said to act as a powerful sexual stimulant and to be of service in im- 
potence dependent upon inability to obtain an erection or when there is 
deficient glandular action. It has also been used in excessive nocturnal 
emissions in masturbators, with asserted great success. In overdoses 
the drug causes gastro-enteritis. Magruder has recommended chloride 
of gold and sodium in the treatment of pertussis. 



GRINDELIA ROBUSTA. 

Grindelia, U. S., is an American plant (Grindelia robusta) containing 
a resin, a volatile oil, and an alkaloid. 

Physiological Action. — Upon the lower animals and man this drug 
is not very powerful in its action, but may cause, in large doses, par- 
alysis of the peripheral sensory nerves, the sensory centres in the spinal 
cord, and finally the motor centres and nerve- trunks. It slows the 
heart by stimulating the vagi, and raises blood-pressure by stimulating 
the vasomotor centre. 

Therapeutics. — Grindelia robusta is an exceedingly useful remedy 
in some cases of asthma and in bronchitis in its later stages. It may be 
given in the dose of 20 to 60 minims (1.3-4.0) of the fluidextract 
(Fluidextr actum Grindelia, U. S.), or by inhaling the fumes of burn- 
ing grindelia-leaves, which have been previously soaked in a solu- 
tion of nitre, dried, and burned on a plate or rolled into a cigarette 
and smoked. In chronic cystitis it stimulates the bladder and is of 
service. By diluting it 1 to 10 with water it forms one of the best 
lotions that we have for the relief of the dermatitis produced by poison 
ivy, or Rhus toxicodendron. 

Administration. — The only preparation which is official is the fluid- 
extract {Fluidextr actum Grindelia, U. S.), dose 20 to 60 minims 
(1.3-4.0). 

GUAIAC. 

Lignum vita?, or Guaiacum officinale, a West Indian tree, is used 
in medicine as guaiac resin (Guaiacum, U. S.; Guaiaci Resina, B. P.), 
or guaiac, which is soluble in alcohol, ether, and chloroform, but is 
insoluble in water. 

Therapeutics. — Guaiac has been largely used in syphilis, but is now 
rarely, if ever, so employed. Given in acute tonsillitis in the dose of 30 
grains in an emulsion made by the use of white of egg, it will often 
abort an attack. In rheumatism it has been largely used. In the 
treatment of gout, Luff has highly commended it as a preventive given 
in cachet or capsule in the dose of 5 grains (0.3) of the powdered 
resin three times a day and gradually increased to 10 grains (0.60) at 
a dose. The ammoniated tincture of guaiac is sometimes employed 
in the treatment of sore throat, particularly if it be rheumatic in type, 



GUAIACOL 297 

but it is a disagreeable preparation to take into the mouth, and the 
salicylates may always be used in its place. 

Administration. — The tincture (Tinctura Guaiaci, U. S.) is given in 
the dose of 5 to 60 minims (0.30-4.0), and the ammoniated tincture 
{Tinctura Guaiaci Ammoniata, U. S. and B. P.) is used in the same 
dose, preferably in milk. Mistura Guaiaci, B. P., is given in the dose 
of J to 1 fluidounce (15.0-30.0). Trochiscus Guaiaci Resina? are 
official in the B. P. 

GUAIACOL. 

Guaiacol (U. S. and B. P.) is a liquid constituting from 60 to 90 per 
cent, of creosote. It is obtained by the distillation of beechwood 
creosote, followed by a complicated process which it is not necessary to 
describe. In other cases guaiacol is obtained from beechwood creosote 
by precipitation with barium hydrate. In still other instances a very 
pure crystalline solid guaiacol is made synthetically from pyrocatechin. 
Much of the "absolute guaiacol" of commerce is impure. Chemically 
pure guaiacol, obtained by the process last named, is a light-colored 
crystalline solid of an agreeable odor and soluble in water in the 
proportion of 1 to 53. It is readily soluble in alcohol and ether. 
As it melts at 83.5° F., it usually is dispensed in a fluid form. 

Therapeutics. — Guaiacol has been largely used by some practition- 
ers, chiefly in Europe, in the treatment of tuberculosis as a substitute 
for creosote, because it is the principal ingredient of that drug. (See 
Creosote.) It was thought by Guttmann, Sommerbrodt, and others 
that the good effect of creosote was due to its destructive action on the 
bacillus, or that it so improved digestion as to indirectly increase the resist- 
ance of the patient to the spread of the disease. Hoelscher and Seifert 
have asserted that guaiacol and creosote produce their good effects 
by forming compounds with the toxins or poisonous albuminoids 
formed by the bacilli, which are then eliminated from the body. 
There is no proof, of this. 

The same rules govern the use of guaiacol as govern the employ- 
ment of creosote. It is best given with brandy, w T ine, or other 
alcoholic drink, or in capsule with cod-liver oil or sweet oil. 5 or 10 
minims (0.30-0.60) of guaiacol may be added to a pitcher of hot water 
and the vapor inhaled three or four times a day in cases of subacute 
and chronic bronchitis. The dose by the stomach is 5 to 20 minims 
(0.30-1.3). In acute follicular tonsillitis pure guaiacol may be painted 
over the tonsils with advantage. Indeed, it is the best application 
for this purpose, in its early stages. 

Clinical observations prove conclusively that guaiacol possesses 
powerful antipyretic influences. As pointed out by Sciolla in 1893, 
guaiacol when painted on the skin of a febrile patient causes a pro- 
nounced fall of temperature, which begins soon after the application is 
made, but is not fully accomplished for from two to three hours. The 



298 DRUGS 

application may be made to the skin of the abdomen, thighs, or chest 
about 30 to 40 minims (2.0-2.6) being used with a brush. When a 
full effect is required, it is well to place an impermeable dressing over 
the part painted to prevent evaporation and aid absorption. These 
applications may be resorted to as often as is necessary for the reduc- 
tion of the fever, and, although the fall of temperature is sometimes 
very rapid and very great — as much as 7° F. in two hours — Da Costa 
asserted that he never had seen serious nervous or cardiac symptoms 
produced, but other observers have noted such untoward results. The 
temperature is very apt to rise speedily after the reduction, and this 
rise is often preceded by a chill. These applications cannot supplant 
the cold bath, although they undoubtedly do reduce the temperature. 
The true sphere of usefulness to be assigned to guaiacol as an antipyretic 
seems to be that of a far less valuable therapeutic measure than the 
bath, and one equally powerful and about as dangerous as are the 
antipyretic drugs of coal-tar derivation. 

The studies of Stolzenberg show that if frequently and constantly 
used guaiacol produces in febrile patients a tendency toward depression. 
Thayer found that great sweating and depression generally follow its 
external use in fevers. Future reports will probably develop the fact 
that in cases of renal irritation guaiacol will prove harmful. 

Guaiacol has been used by painting it on the affected part in the 
treatment of superificial neuralgias, and in deep-seated nerve-pains, as 
in sciatica, it has been given hypodermically, in the dose of 2 minims 
in 10 minims of spirit of chloroform, injected deeply into the neighbor- 
hood of the painful nerve. 

If guaiacol is placed upon the skin by means of a small compress, 
which has been wet with it and bound tightly to the part, local anaes- 
thesia is rapidly developed; but if left in place too long, it may be 
absorbed in sufficient amount to cause depression or a fall of temperature. 

Belfield highly recommends painting the scrotum with guaiacol 15 
minims (1.0) and glycerin 45 minims (3.0) for orchitis, or an ointment 
of guaiacol 1 drachm (4.0) to 4 drachms (16.0) of lanolin may be 
rubbed into the scrotum and applied on lint. This should be applied 
every other day. 

A serious objection to the external use of guaiacol is its disagreeable 
odor. 

GUAIACOL CARBONATE. 

Carbonate of guaiacol (Guaiacolis Carbonas, U. S. and B. P.) is a 
white, crystalline powder, consisting of 91.5 per cent, of pure guaiacol 
and 8.5 per cent, of carbonic acid. This powder is insoluble in water, 
soluble in 60 parts of alcohol and 1 part of chloroform, neutral in 
reaction, and is said to be without irritating effect on the stomach. 
Taken by the healthy individual, it is decomposed into guaiacol and 
carbonic acid in the bowel, but not in the stomach, and it is used for 
this reason, as salol is, as an intestinal antiseptic, in the various forms 



H AM AM ELI S 299 

of fermentative diarrhoea and typhoid fever. The drug is said to be 
slowly absorbed, but after absorption is rapidly eliminated. Its 
therapeutic applications in tuberadosis are practically identical with 
those of pure guaiacol, save that it is more readily borne by the 
stomach than the latter drug. Guaiacol carbonate may be given in 
capsule or pill, or it may be given in dry powder on the tongue in the 
dose of 2 to 10 grains (0.12-0.60). Usually in typhoid fever the dose 
is about 2 grains (0.12) every three hours, and in tuberadosis of the 
lungs 5 grains (0.30) three times a day. 

H-ffiMATOXYLON. 

Hoematoxylon , Hamatoxyli Lignum, B. P., or logwood, is the heart- 
wood of TIamatoxylon campechianum , a tree of the American tropics. 
It contains an active principle, hsematoxylin. 

Therapeutics. — Hsematoxylon is a mild astringent, very useful in 
serous diarrhoeas and the diarrhoeas of young children, as children do 
not dislike it, owing to its agreeable taste. (See article on Diarrhoea.) 
As it colors the stools and urine red, the nurse should be warned lest 
she be alarmed at the sight of what looks like blood on the diaper after 
the drug is given to infants. If the urine is alkaline, the color may be 
violet or red. In leucorrhoea its internal use is said to be of service. 
The extract (Extractum Hcematoxyli) is given in the dose of 8 to 30 
grains (0.5-2.0), and Decoctum Hoematoxyli, B. P., in the dose of 
1 to 2 fluidounces (30.0-60.0) . An unofficial fluidextract is often to be 
found in the shops. The dose of this is \ to 2 fluidrachms (2.0-8.0). 
(See article on Diarrhoea.) 

HAMAMELIS. 

Hamamelidis Cortex and Hamamelidis Folia, B. P., witch-hazel, 
or Hamamelis virginiana, is a plant of the United States, devoid of 
any active principle, but possessing considerable remedial power. 

Therapeutics. — Hamamelis is to be employed in relaxed sore throat 
resulting in congestion and hyperemia following exposure or where 
mild catarrhal states are present. Similarly, it is employed in an 
atomizer, after attacks of acute coryza, to tone up the nasal mucous 
membrane. The strength of the solution should be 20 to 60 minims 
(1.3-4.0) of the distilled extract to the ounce (30.0) of water. Hama- 
melis when taken internally is often very successful in the treatment 
of uterine oozing from small bloodvessels, seems to do good even in 
hcsmatemesis and haemoptysis, and will sometimes arrest hematuria 
when all other remedies fail. Applied by means of cloths to recent 
leg ulcers, it rapidly relieves the angry-looking skin surrounding the 
ulcer. The limb should be elevated and at rest while the treatment 
is pursued. In bleeding from the bladder it may be injected into this 
viscus daily in the form of the distilled fluidextract. Taken inter- 
nally and applied locally, it is of value in the treatment of bleeding 
and the so-called blind piles. (See Hemorrhoids.) 



300 DRUGS 

Administration. — The official preparation in the U. S. P. is the 

distilled extract (Aqua Hamamelidis, U. S.), which is a perfectly clear 
fluid, given in the dose of from 30 minims to 1 drachm (2.0-4.0). 
It is much the best preparation for internal and external use. The 
B. P. recognizes a solution, Liquor Hamamelidis, Tinctura Hamamelidis, 
and Unguentum Hamamelidis and Eiiractum Hamamelidis Liquidum. 

HELMITOL. 

Helmitol is hexamethylen-tetramine anhydro-methylen-citrate. It 
occurs as a white crystalline powder, of slightly acid taste, and is 
soluble in water 1 to 10 parts. 

In action it closely resembles hexamethylenamine (which see), 
but gives off formaldehyde from both its hexamethylen-tetramine 
and its anhydro-methylen-citrate. It is said to be a much more 
powerful urinary antiseptic than hexamethylenamine, and to be 
equally efficacious whether the urine be acid or alkaline. It is also 
said to be less irritant to the kidneys. Helmitol is used for all the 
purposes named under "Hexamethylenamine." The dose is 5 to 15 
grains (0.3-1.0), dissolved in water, three or four times a day. 



HEROIN. 

Heroin (Diacetylmor pinna 3 hydrochloridum, U. S.; Diamorphince 
hydrochloridum, B. P.) is a white crystalline powder without odor 
and possessing a slightly bitter taste. It is used in medicine for 
the purpose of controlling excessive cough. Under its influence the 
respirations are usually slightly slowed and deepened. At one time 
it was thought to be less depressant to the respiratory centre than 
morphine, and even stimulant in its influence, but Cushny has shown 
that it is a more powerful respiratory depressant than morphine, 
The dose is ^o" to e grain (0.003-0.01), three times a day. Large 
doses do not act as well as small ones as a rule. It is said to be of 
value in urcemic dyspn&a. The fact that it does not stupefy the 
patient nor produce constipation is strongly in its favor. As heroin 
is insoluble, hydrochloride of heroin is the preparation used for watery 
solutions; or heroin itself may be dissolved in water to which a little 
acetic acid has been added. It may also be given in pill or powder 
with white sugar. Like all derivatives of opium its repeated use may 
develop a habit. 

HEXAMETHYLENAMINE. 

Urotropin (Hexamethylenamine, U. S., Hexamine, B. P.), also made 
in the L nited States under the name uritone, is produced by the 
action of ammonia upon formaldehyde, and appears in colorless 
crystals which are odorless and have an alkaline reaction. At 77° F. 



HOFFMAXX'S AXODYXE 301 

it dissolves in 1.5 parts of water. When taken internally it sets free 
formaldehyde in the urine. Burman states that 10 grains three 
times a day will give approximately 1 : 5000 of formaldehyde in the 
urine. Formaldehyde appears in the urine in from one to three hours 
after a dose is given, its maximum appears in from four to eight hours. 
It is used to render the urine acid and clear when this secretion is 
excessively alkaline, loaded with phosphates and amorphous urates, 
and purulent. It allays irritability of the bladder due to this cause, 
as, for example, that due to ammoniaeal cystitis. In pyelitis and 
cystitis the microorganisms present in the urine should be isolated, 
and if it be the colon bacillus, acid sodium phosphate (XaH^PoJ^O) 
in 10-grain (0.65) doses, dissolved in plenty of water, be given every 
two or three hours so as to make the urine acid, since more formalde- 
hyde is liberated from the urotropin if the urine is kept acid and an 
acid urine is not favorable to the growth of the colon bacillus. Indeed, 
it may be said that, unless the urine in the bladder is acid, enough 
formaldehyde is not set free to do any good. It is chiefly in the 
bladder and not in the kidneys that the drug is decomposed. Urotro- 
pin is largely employed to render the urine sterile in cases of typhoid 
fever and to act as an intestinal antiseptic. For the former purpose it 
is of great value not only in avoiding secondary vesical diseases, but in 
preventing the spread of typhoid fever to others. Investigations indi- 
cate that when large doses are given some of it is eliminated by the 
liver in the bile, and also by the walls of the gall bladder and mucous 
membrane of the nose. For this reason its use in enteric fever to 
prevent cholecystitis is important. Crowe has also shown that it 
appears within an hour in the cerebro-spinal fluid, and although doubt 
has been thrown on this statement, in that the spinal fluid being 
alkaline does not set free formaldehyde, nevertheless it may be used 
in traumatisms of the brain and cord to prevent infection. Doses 
about double the ordinary amount are used for this purpose. 

In the presence of an epidemic of poliomyelitis it may be used as a 
prophylactic, or even with the hope that it may modify the disease 
when developed. Urotropin is also useful to abort acute coryza. 

In ordinary cases the dose is 10 to 30 grains (0.65-2.0), taken two 
or three times a day, dissolved in a half-pint of carbonated or plain 
water, but in some cases larger doses are needful. (See Helmitol.) 

Where a full effect is required smaller doses may be given five or six 
times a day, and it may be given in keratin-coated pills, since every 
grain altered by acid in the stomach produces that much less effect in the 
bladder. The continued use of large doses has resulted in hematuria and 
strangury. 

HOFFMANN'S ANODYNE. 

Spirihis JEtheris Compositus, B. P., consists of alcohol, ether, and 
the heavy oil of wine. It is no longer official in the U. S. P., but 
is largely used. The writer has experimentally studied very thor- 
oughly the action of the last-named ingredient, and finds: 



302 DRUGS 

First. That the belief in heavy oil of wine being the quieting agent 
in Hoffmann's anodyne is fallacious. 

Second. The calmative effects of this mixture depend largely on 
the ether, rather than on the oil. 

Third. It would seem probable that in Hoffmann's anodyne we 
possess an agent in which there are linked together three drugs of 
undoubted power, each one of which successively substitutes the other, 
stimulating the system in the order here named — viz., ether, alcohol, 
and the heavy oil of wine. 

Therapeutics. — Hoffmann's anodyne is the best carminative that 
we possess for general use, and is one of the best remedies for singultus 
or hiccough. This effect is accomplished by the alcohol and ether 
acting as irritants or stimulants to the stomach and intestine, so that 
free peristalsis results. In angina pectoris this drug is often the best 
remedy we have during the attack. In the cardiac palpitation of 
tobacco-heart or in that arising from indigestion and in the nausea and 
depression seen after excessive smoking it is also very useful. 

In sudden collapse in infants the following may be used with ad- 
vantage: 

1^ — Spiritus aetheris compositi, 
Spiritus ammoniae aromatici, 

Tincturae aurantii aa TTLx (0.65). 

Aquae camphorae f5j (4.0). — M. 

S. — Give at one dose in a little water. 

Hoffmann's anodyne should always be given in capsule or in cold 
water, preferably ice-cold, in order to prevent too rapid volatilization 
of the ether and consequent difficulty in swallowing the liquid. 

The dose is 1 to 2 drachms (4.0-8.0) to an adult. The vapor of the 
ether is so irritating that the drug is difficult of administration to very 
young children. 

HOLOCAINE. 

Holocaine is a synthetic substance allied to phenacetine, which is 
almost insoluble in cold water, and which is therefore commonly 
employed in the form of the soluble hydrochloride. This salt is a 
white crystalline body, which is stable when brought in contact with 
many agents, but is readily decomposed by alkalies. Solutions of this 
preparation possess distinct antiseptic power, and therefore do not 
require boiling in order that they may be sterile. As the drug when 
in solution gradually loses its anaesthetic power, it should be freshly 
dissolved each time it is needed. 

Holocaine is used as a local anaesthetic for the eye in place of cocaine, 
usually in the strength of 1 per cent. Its effects begin in about fifteen 
seconds to one minute, and last about five to fifteen minutes. It does 
not dilate the pupil as does cocaine, nor does it affect intraocular ten- 
sion or roughen the corneal epithelium. Holocaine has not supplanted 
cocaine, but, for the reason just given, is useful in cases requiring 



HONEY 303 

anaesthesia and yet at the same time suffering from keratitis or iritis. 
It does not cause primary ischsemia or secondary hypersemia of the 
mucous membrane as does cocaine. 

HOMATROPINE. 

Homatropine is an artificial alkaloid obtained by prolonged and 
gentle heating of a solution of equivalent quantities of tropine 1 and 
toluic acid in hydrochloric acid. The hydrobromide of homatropine 
(Homatropince Hydrobromidum, U. S. and B. P.) is a crystallizable salt 
of homatropine, soluble in 5.7 parts of distilled water. The B. F. 
recognizes discs of homatropine (Lamella? H omatropince) . 

Hydrobromide of homatropine, properly applied by frequent instil- 
lations, is a reliable mydriatic when it is desired to correct anomalies of 
refraction in healthy eyes. Experience is not at hand to determine its 
value for this purpose in eyes affected with retinal-choroidal disturbance. 
Atropine and hyoscyamine are preferred under such circumstances, 
for the obvious reason that their prolonged action is desirable as 
a method of treatment. The danger of systemic disturbance from 
homatropine is remote, even when repeated instillations have been 
made, and its temporary action upon the pulse causes no inconvenience 
to the patient. Slight hyperemia of the conjunctiva almost invariably 
follows its use, but true conjunctivitis, if it occurs at all, must be 
excessively rare. According to the studies of de Schweinitz and the 
writer, the drug has a physiological action closely allied to that of 
atropine, from which it is derived. Homatropine mydriasis generally 
lasts from thirty-six to forty-eight hours, that of hyoscyamine eight to 
nine days, and that of atropine ten to twelve days. For the production 
of ordinary mydriasis the drug should be used in solution of the strength 
of 4 grains (0.25) to the ounce (30.0) of distilled water, which is to be 
dropped into the eye every five or ten minutes. As the drug is expensive 
only a few drachms of the solution of the strength named should be 
ordered for a patient. 

HONEY. 

Honey, or Mel, U. S., is the saccharine fluid deposited in combs b\ 
the honey-bee, or Apis mellifica. It is used in medicine to mask the 
taste of disagreeable medicines. When it is abstracted from a par- 
ticular variety of flowers, it frequently has the odor of the flowers, and 
when taken internally may even produce the physiological or poisonous 
effects of the plant from which it is gathered. This accident occurs 
commonly in those parts of the country where the bees have had access 
to mountain laurel and similar plants. 

Therapeutics. — Honey mixed with water is used as a vehicle in 
gargles and to relieve cough and dryness of the mouth and fauees. When 

1 Tropine is a product obtained by splitting up atropine into tropine and tropic acid. 



304 DRUGS 

used as a gargle it very distinctly increases the secretion of the mucous 
membrane, and so relieves the congestion. 

Under the name of Oxymel the B. P. recognizes a mixture of 8 parts 
of honey, 1 of acetic acid, and 1 of water. This is generally used as a 
vehicle for more active remedies in gargles or even for expectorant 
mixtures. Melted and strained honey, to which a small proportion 
of glycerin is added, is known as Mel Depuration, U. S. and B. P. 
There are also a honey of roses (Mel Roses, U.S.) and a confection 
(Confectio Rosce, U. S.) used as vehicles for other drugs. Mel Boracis, 
B. P., is used for the same purposes and for stomatitis. 

The objection to the use of honey in vehicles for active medicines 
is the fact that it is apt to disorder the stomach. 

HOPE'S CAMPHOR MIXTURE. 

This is a mixture originally made with nitrous acid, but largely 
used at present with nitric acid, owing to the fact that nitrous acid 
is changed into nitric acid when water is added to it. The nitrous 
acid is, however, more efficacious than nitric acid in the serous or 
choleraic diarrheas which it is used to combat. The formula is as 
follows : 

I$— Acidi nitrosi f^j (4.0). 

Aquse camphorse f §viij (240.0). 

Et adde 

Tincturse opii gtt. xl (2.6).— M. 

S. — One-fourth of this in water every three or four hours. 

HOPS. 

Humulus, U. S., is the strobiles of ordinary hops, or Hamulus 
lupulus. These contain a liquid volatile alkaloid, lupuline, and a 
bitter principle, lupulinic acid. Much confusion has arisen in regard 
to the preparations of this drug, partly because humulus is the official 
name in the U. S. P. and lupulus in the B. P. This confusion has 
been increased by the fact that the alkaloid of hops is called lupuline, 
while the powder which is found on the strobiles is called lupulin. 
Hops possess so little power that all the preparations official in the 
U. S. P. of 1900 have been excluded in the present issue. 

Therapeutics. — Hops are used as antispasmodics and nervous seda- 
tives in cases of hysteria and nervousness. In priapism, vesical irrita- 
bility, and renal irritation they are of service. Even in delirium tremens 
they seem to be of value. For local application a hop poultice may be 
made by placing the powdered strobiles in the mass, and employed 
in this way they are a favorite domestic remedy for local painful 
inflammations. Hops have been used in the form of a hop pillow 
in nervous insomnia, but the soporific influence is largely imaginary 
or depends on the fumes of the alcohol with which the pillow is 
moistened. 

Administration. — The tincture is given in the dose of \ to 3 ounces 



HYDRASTIS 305 

(16.0-90.0). Lupulin (Lupulinum, B. P.), which is the powder 
found on the strobiles of hops, is given in the dose of 2 to 5 grains 
(0.12-0.30) or more; and the fluidextract in the dose of 30 to 120 
minims (2.0-8.0). The preparations of the B. P. are the infusion, 
dose 1 to 2 fluidounces (30.0-60.0), and the tincture, dose J to 1 
. fluidrachm (2.0-4.0). 

HYDRASTIS. 

Hydrastis, U. S., or Hydrastis Rhizoma, B. P., is the dried rhizome 
and root of Hydrastis canadensis, sometimes called golden seal, 
containing two alkaloids known as hydrastine and berberine, and, 
perhaps, xanthopuccin. It should yield not less than 2.5 per cent, of 
hydrastine. 

Physiological Action. — When given to one of the lower animals in 
poisonous doses hydrastis may cause spinal convulsions followed by 
paralysis, according to the quantity of berberine or hydrastine present. 
The latter is more convulsive in its effects than the former. Upon 
the circulation hydrastine, when injected into the jugular vein, causes 
a primary fall of arterial pressure, succeeded by a decided rise, and 
the studies of Cerna have proved that it is an active poison. When 
given to man in medicinal amounts its effect on vital functions is very 
slight indeed. 

Therapeutics. — Hydrastis is of service in chronic gastro-intestinal 
catarrh, particularly that following the abuse of alcohol, and may be 
used as a stomachic and tonic after malarial fever and similar depress- 
ing diseases. Wherever mucous membranes are in a condition of 
lowered tone this drug is indicated. Thus in catarrhal jaundice of a 
subacute type, in uterine catarrh, in leucorrhoea dependent upon a 
relaxed state of the vagina, and in chronic nasal inflammations and 
irritations it will be found useful. 

Tincture of hydrastis is said to possess a distinct antimalarial influ- 
ence, but this is doubtful. 

One of the best remedial measures that we have in the later stages 
of gonorrhoea, when the acute period has passed, is the local and inter- 
nal use of hydrastis. If it is used as an injection, 5 grains (0.3) of the 
commercial hydrastine to each ounce (30.0) of water should be em- 
ployed twice a day. Belfield has highly recommended the following 
formula for use in this disease prior to the tenth day: 

1$ — Hydrastinae hydrochloridi gr. v (0.3), 

Protargol gr. v (0.3). 

Glvcerini f 3 88(2.0), 

Aquae destillatse .... q. s. ad f 5j (30.0).— M. 
S. — Precede with a hot-water injection and use four to six times daily, 'telling 
the patient to retain it five to ten minutes each time. 

The following infusion will be found of service in vaginal gonorrhoea 
and leucorrhoea: Take 1 drachm of the powdered root and add it to 
20 



306 DRUGS 

8 ounces of boiling water; J to 1 dram of the fluidextract may also 
be added to a pint of water and used as a wash. 

Administration — The fluidextract (Flnidextractum Hydrastis, U. S. ; 
Extractum Hydrastis Liquidum, B. P.) may be given in the dose of 

5 to 30 minims (0.30-2.0) and it should contain not less than 2.0 Gm. 
of hydrastine in each 100 mils. The dose of the tincture (Tinctara 
Hydrastis, U. S. and B. P.) is from 30 minims to 2 drachms (2.0-8.0), 
and it should contain 0.4 Gm. of hydrastine in each 100 mils. The 
Glyceritum Hydrastis, U. S., is used as a healing application to mucous 
membranes. Extractiivi Hydrastis, U. S., is given in the dose of 1 
grain (0.06). 

Much doubt exists as to the dose of hydrastine. This arises from 
the fact that two forms of it are sold. That most commonly seen is 
a dark-brown mass which is very impure, and contains berberine 
and other substances. Its dose of this is 3 to 10 grains (0.20-0.60). 
The pure hydrastine (Hydrastina, U. S.), as made by Merck, is given 
in the dose of J to J grain (0.015-0.03). Hydrastinine hydrochloride 
(Hydrastina 3 hydrochhridum, U. S.) an artificial alkaloid of hydras- 
tine, dose \ to 1 grain (0.03-0.06). 

HYDRIODIC ACID. 

Acidum Hydriodicum Bilutum (U. S. and B. P.) is a solution of 
hydriodic acid containing not less than 10 per cent, of absolute acid 
and about 90 per cent, of water. It should be kept in amber-colored 
glass-stoppered bottles and be protected from light. 

Its physiological and therapeutic action is practically identical with 
the other iodides (which see). If discolored, due to free iodine, it 
should be discarded. The dose is 5 to 40 minims (0.3-2.6), well diluted 
with water. 

The syrup of hydriodic acid (Syrupus Acidi Hydriodici, U. S. and 
B. P.) containing 1 part of dilute hydriodic acid to 3 of water and 

6 of syrup, is the preparation commonly employed, and it is an efficient 
substitute for the other iodides. The dose is from 1 to 4 drachms (4.0- 
16.0), well diluted with water, and taken one hour after meals. 

HYDROBROMIC ACID. 

(See Bromides.) 

HYDROCHLORIC ACID. 

Acidum HydrocMoricum (U. S. and B. P.) is a clear, colorless liquid, 
possessing an acid odor and taste, devoid of astringency, but in 
concentrated form decidedly caustic. It should be kept in dark- 
colored bottles. In the strength of 0.2 per cent, it is normally present 
in the gastric juice, and aids the pepsin in the conversion of proteids 
into peptones and in the formation of pepsin from pepsinogen. 



HYDROCYANIC ACID 307 

Therapeutics. — Hydrochloric acid is indicated only in certain forms 
of indigestion. With new methods of studying gastric secretions we 
have learned that it is of value in those cases in 'which the gastric 
secretion of HC1 is deficient. Thus it is given to aid digestion during 
and after fevers, when this acid is apt to be absent from the gastric 
juice, particularly in typhoid fever. In cases of gastric cancer, when 
this acid is usually absent from the gastric secretion, and in the sick 
stomach following an alcoholic debauch, it is of great service. In 
some cases of chronic gastric catarrh with dilatation, in which there is 
atrophy of the gastric tubules, it should be used freely. The dose of 
the dilute acid (Acidum Hydrochloricum Dilutum, U. S. and B. P.) is 
5 to 20 minims (0.30-1.3). (See Indigestion, Part IV.) 

A useful prescription in such cases is: 

1$ — Acidi hydrochlorici diluti . . . . . f oij (8.0). 

Essentia? pepsini . . . . . . t'oj (30.0), 

Tincturae gentianse composite . q, s. ad fgiv (120.0). — M 
S. — Dessertspoonful (8.0) in a little water with meals. 

This acid is combined with nitric acid to form dilute nitro-hydro- 
chloric acid (Acidum Nitro-hydrochloricum Dilutum, U. S. and B. P.). 
the dose of which is 10 to 30 minims (0.6-2.0), 5 to 20 minims 
(0.3-1.3), B. P.; also the pure acid (Acidum Nitro-hydrochloricum; 
U. S.), dose 1 to 5 minims (0.05-0.30). 

Hydrochloric acid causes, when taken in poisonous doses, violent 
gastro-enteritis and corrosion of the gastric walls, and its action should 
be combated by alkalies, soap, oils, and white of egg, and the use of 
opium to relieve pain and irritation. 



HYDROCYANIC ACID. 

Hydrocyanic or Prussic Acid is a transparent, colorless, very volatile 
liquid, giving rise to vertigo when inhaled in minute amounts and 
capable of producing death if the fumes be concentrated. If the bottle 
containing the pure drug be opened, it should be done where there is 
sufficient draught between windows to prevent any contamination of 
the atmosphere of the room by the acid. 

Pure hydrocyanic acid is never used in medicine ; the form employed 
is the dilute acid (Acidum Hydrocyanicum Dilutum, U. S. and B. P.), 
which contains about 2 per cent, of the drug in water. It must be 
kept in dark, tightly-stoppered bottles. 

Physiological Action. — This is one of the most rapid (if not the most 
rapid) of the lethal poisons, only being approached by carbolic acid and 
nitrobenzole in the violence of its effects. Owing to its volatility, it is 
absorbed with great rapidity, and acts upon the respiratory centre and 
the heart, being eliminated almost immediately afterward. Because of 
its fleeting character, the survival of a patient twenty or thirty minutes 
after the ingestion of a poisonous dose is a favorable sign for his recovery. 



308 



DRUGS 



The drug is an active paralyzant and exerts a lethal influence over 
every part of the body. The nervous system, heart, respiration, brain, 
and all vital parts are killed at once if much of it is present. 



Fig 




Tracing of the deep stormy respirations of an animal under the influence of hydrocyanic acid. 
(After Schmiedeberg.) I, normal respirations; II, acid inhaled; III, violent deep respirations; 
IV, arrest of respiration. 

Poisoning. — When a lethal dose of hydrocyanic acid is taken, death 
either comes at once, so that the person drops dead with a gasp, is for a 
moment convulsed, the face cyanotic, the eyes wide open, with the teeth 
tightly clinched, and the lips covered by a bloody froth, or three stages 
of poisoning may ensue if the dose has not been large enough to result 
in immediate death, owing to its slow absorption. In the first of 
these stages there are difficult respiration, slow cardiac action, and 
disturbed cerebration. In the second stage, which is convulsive, 
there are present wild cries, dilated pupils, unconsciousness, vomiting, 
spasmodic urination and defecation, erections of the penis, and ejacula- 
tions of semen. In the third stage there are asphyxia, collapse, and 
paralysis ending in death. The blood is found to be dark and venous- 
looking, but does not give the spectrum bands of cyano-hsemoglobin. 
These bands only appear when the drug is shaken with blood outside 
the body. 

The diagnostic signs of death from prussic acid are the odor of the 
^cid about the body, the wide-staring eye, the clinched teeth covered 
with froth, and the livid, cyanosed face. If the body be opened, the 
odor of hydrocyanic acid is marked, but this rapidly passes away, 
owing to the volatility of the drug. 

The only poison producing symptoms resembling those which have 
just been described is nitrobenzole, or essence of mirbane, which has 
a somewhat similar odor, but which is, however, more permanent, the 
odor remaining for hours in the opened body. 

Therapeutics. — Hydrocyanic acid is useful in cases of gastralgia of 
purely nervous origin, in some cases of nervous vomiting, and in 
irritable stomach, where, owing to hyperesthesia of the mucous mem- 
branes, the taking of food produces discomfort. 

In irritable coughs, due to tickling in the throat and bronchi, it is 
very extensively used, and has received high praise by those best 



HYDROGEN PEROXIDE 309 

qualified to judge. On the other hand, it has been claimed that owing 
to the extreme volatility of the drug it acts only for the moment, and 
that a dose every ten or fifteen minutes is necessary to produce any 
constant effect. However this may be in theory, practically the acid 
certainly does aid in relieving cough. In these states the following 
prescription will be found of service: 

1$ — Acidi hydrocyanici diluti f oj (4.0). 

Syrupi pruni virginianse f §iij (90.0). — M. 

S. — Teaspoonful (4.0) every four or five hours to an adult. 

In enteralgia or neuralgia of the intestine dilute prussic acid is 
often a very useful remedy. 

Externally, the drug is useful in pruritus and other forms of itching 
shin diseases, and the following formula will be found of service in 
pruritus vulva": 

Bf — Hydrargyri chloridi corrosivi gr, iss (0.09). 

Acidi hydrocyanici diluti f oj (4.0). 

Aquce amygdalae amarse f §vj (180,0). — M. 

S. — Poison! For external use. Apply to the itching surface with a small rag. 

The same prescription may also be employed in pruritus without 
the bichloride, if so desired. The dose ot dilute hydrocyanic acid is 
1 to 5 minims (0.05-0.30). In certain forms of irritable cough inhala- 
tions of the vapor (Vapor Acidi Hydrocyanici) are recommended; 
this is prepared by adding 10 to 15 minims (0.60-1.0) of the diluted 
acid to 1 fluidrachm (4.0) of water, which is then placed in a suitable 
apparatus, from which is inhaled the vapor that arises. 



HYDROGEN PEROXIDE. 

Peroxide of hydrogen is a clear, odorless, syrupy fluid of a specific 
gravity of 1.452, possessing a harsh, bitter taste. It is readily soluble 
in water, and its chemical formula is H 2 2 . Pure peroxide of hydrogen 
is never used in medicine, but in solutions of varying strength. The 
ordinary solution, as found in the shops and that now official (Liquor 
Hydrogenii Dioxidi, U. S., Liquor Hydrogenii Peroxidi, B. P.), is 
a slightly acid, aqueous solution of hydrogen dioxide, which should 
contain, when freshly prepared, about 3 per cent., by weight, of absolute 
hydrogen dioxide, corresponding to about 10 volumes of available 
oxygen. It should be kept in a cool place. Upon removing the stopper 
from the bottle not more than a slight pressure should be observed. 
It is a colorless liquid, liable to deteriorate upon keeping or on pro- 
tracted agitation, without odor, slightly acidulous to the taste, and 
producing a peculiar sensation and soapy froth in the mouth. If the 
stopper in the bottle be replaced by a pledget of cotton, deterioration 
is retarded. When exposed to the air at the ordinary temperature, 
or when heated on a water-bath at a temperature not exceeding 60° C. 
(140° F.), the solution loses chiefly water. When rapidly heated, it 



310 DRUGS 

frequently decomposes suddenly. The term "10 volumes" signifies 
that it can yield 10 volumes of available oxygen, and it is upon this 
yield of oxygen that its activity depends. The acid reaction is due to a 
small amount of acid added to the solution to preserve it. This can 
be neutralized by the addition of a little sodium bicarbonate just before 
it is used. The official solution of peroxide of hydrogen, while the 
most stable that can be prepared, is nevertheless readily deteriorated 
by exposure to heat, sunlight, or prolonged shaking. If placed in 
an absolutely clean, smooth glass vessel it may be concentrated for 
immediate use by exposing it to a temperature of 140° F. ; but exposure 
to a temperature above this point may result in its decomposition 
with explosive violence. Practically, this means of concentration is 
not convenient for the practitioner, and the ordinary official solution 
fulfils all ordinary requirements unless it has deteriorated by age. 
The great difficulty in the use of the solution of the peroxide is its 
liability to undergo a change and become practically worthless. Wallian 
states that as a rough test for the value of a given solution a few crystals 
of permanganate of potassium may be placed in a test-tube, and 1 to 
2 drachms (4.0-8.0) of the solution added. The violence of the 
resulting effervescence is indirect ratio to its value as a remedial agent. 
Marshall has proved that the constituent of blood and pus that sets 
free the oxygen from this drug is globulin. 

Therapeutics.— -The most valuable use of the peroxide-of-hydrogen 
solution in medicine is in the treatment of diphtheria. So far as we 
know, it is the best application for the destruction and removal of the 
false membrane. There is no injury to the normal tissues nor is there 
the danger of poisoning which sometimes follows the use of such drugs 
as carbolic acid. Applied to the false membrane, there is at once an 
active effervescence with some local tingling of the part. The mem- 
brane can afterward be removed in shreds. The solution should be 
applied by means of a swab or spray, but if the latter is used a 
glass atomizer must be employed, as the peroxide is decomposed by 
coming in contact with metals. Peroxide of hydrogen is also a very 
valuable application for cases of follicular tonsillitis with profuse 
exudation, to cleanse the parts prior to the use of guaiacol. (See 
Guaiacol.) 

In the treatment of abscess-cavities, tubercular or septic in character, 
the peroxide of hydrogen is a very valuable application, and its use 
will often decide the presence of pus, since when it meets with this 
material active effervescence ensues; but care must be exercised that 
free vent is allowed for the gas that is given off, as if confined it will 
force the septic material into the surrounding healthy tissues. Simi- 
larly, it is a valuable preparation for cleansing infected wounds, ulcers, 
and malignant growths which have ulcerated. * 

Hydrogen peroxide is a useful agent for the removal of powder- 
stains in recent cases. 

It is stated that the application of this liquid to the spot affected 



HYOSCYAMUS 311 

by a hornet's sting will give instant relief; and applied by means of 
aii atomizer it is the best fluid to aid in the painless removal of adhe- 
sive strips. The part of the strip next to the skin should be sprayed 
as it is gradually pulled off. It is also used on plaster-of-Paris 
dressings to soften the material so that it can be cut with a knife or 
shears. 

Where the peroxide is used as a gargle or mouth-wash it may produce 
pain through its attacking cavities in the teeth or the metallic substances 
with which they are filled. When so used it should always be diluted, 
1 part to 3 of water. 

The employment of the peroxide internally, with the idea that it 
will yield oxygen to the body in cases in which this gas is lacking in 
the blood, is futile. Even if the oxygen entered the blood, the amount 
disengaged from a possible dose would be too small to be of value. 

Taken internally the peroxide of hydrogen is not poisonous. The 
internal dose of the Liquor Hydrogenii Dioxidi of the U. S. P. is from 
1 to 4 drachms (4.0-16.0), well diluted with water, and taken from a 
porcelain, not a metal, cup or spoon. It possesses no distinct value 
in internal medication. 

HYOSCYAMUS. 

Hyoscijamus, U. S., or henbane, is a plant of the Northern United 
States and Europe. It is the dried leaves and flowering tops of Hyos- 
cyamus niger, collected from plants of the second year's growth, and 
should contain not less than 0.08 per cent, of mydriatic alkaloids. The 
leaves (Hyoscyami Folia, B. P.) only are used, and from them are 
obtained two alkaloids — one known as hyoscyamine, the other as 
hyoscine. (See Hyoscine.) The first has practically the same physio- 
logical action as atropine, save that it is more sedative in its effects on 
the nervous system. (See Belladonna.) The second is quite different 
in its influence over the body. The only marked difference in the action 
of hyoscyamine and atropine upon the eye is in the mydriasis produced 
by each. While that of atropine lasts, in man, from twelve to four- 
teen days, hyoscyamine generally remains for only seven to nine days. 
Sometimes the development of mydriasis is preceded by violent pain 
in the eye due to a cramp of the ciliary muscle. If so, the drug must 
be pushed to overcome the spasm. The strength of the solution to 
be used is 2 grains (0.12) to the ounce (30.0). Owing to the presence 
of hyoscine in hyoscyamus, it is more quieting and depressing to the 
nervous system than is belladonna. 

Therapeutics. — Hyoscyamus is used in every condition indicating 
the employment of belladonna; or, in other words, wherever local 
spas in or arterial relaxation exists or where pain is due to spasm. It 
has been particularly recommended in nervous cough, in whooping- 
cough, and in colic, and probably is better in its influences in these 
states than is belladonna. In combination with nitrate of silver the 
extract may be used with advantage in chronic gastric catarrh and 



312 DRUGS 

gastric ulcer. In urinary incontinence due to irritable bladder it is very 
serviceable, and particularly is this true of this affection in children 
and old persons, provided that the urine is first rendered normal by 
the use of acidifying drugs or by the use of alkalinizing drugs if it is 
abnormally acid. 

Administration. — The drug itself is official in four forms and as 
hyoscy amine sulphate and hydrobromide. The dose of the tincture 
{Tinctura Hyoscyami, U. S. and B. P.) is 10 to 40 minims (0.6-2.6), 
J to 1 fluidrachm (2.0-4.0), B. P., and should contain 0.007 Gm. of 
mydriatic alkaloids in 100 mils. ; the alcoholic extract (Extractum Hyos- 
cyami, U. S. and B. P.), dose \ to 1 grain (0.03-0.06), 2 to 8 grains 
(0.12-0.48), B. P., should contain 0.3 per cent, of total alkaloids; 
the alkaloid (Hyoscyamince Hydrobromidum, U. S.), dose -£$■ to 5 \ grain 
(0.001-0.0015), 2^0 to y^o grain (0.0003-0.0006), B. P.; the fluid- 
extract (Fluidextractum Hyoscyami, U. S.) contains 0.075 Gm. of 
alkaloids in each 100 mils., and is given in the dose of from 2 to 10 
minims (0.10-0.60). 

Hyoscine. 

This is one of the alkaloids derived from hyoscyamus, and is a thick, 
syrupy substance which forms a crystalline salt with an acid. It has 
been largely supplanted by scopolamine, to which the name Hyoscine 
has been given. Some clinicians claim that although these alkaloids 
are chemically identical their therapeutic effect is different. (See 
Scopolamine.) 

Hyoscine is official in the form of Scopolamine Hydrobromide 
{Scopolamince Hydrobromidum , U. S. and B. P.). 

Physiological Action. — Hyoscine quiets the cerebrum and produces 
deep sleep in a certain class of patients. In the lower animals or in 
man it may cause sleep or wild delirium. It causes loss of reflex action 
in overdose, which is due to depression of the spinal cord and not of 
the nerve-trunks. Upon the circulation it has little effect, but it is 
worthy of note that it influences the vagus nerves, as does atropine, 
stimulating them at first, but finally depressing them, although the 
contrary has been asserted. In any event, the circulatory effect is a 
minor one. 

In cases where hyoscine has acted in excess, or where an overdose 
has been given, pilocarpine may be used as a physiological antidote 
in full doses if the heart is sound. 

Therapeutics. — Hyoscine is of value as a hypnotic in a very limited 
class of cases, and in this class generally acts most favorably. These 
cases consist of those who, from acute mania, hysteria, or similar cause, 
suffer from insomnia, and perhaps struggle violently against proper 
control or refuse to swallow or retain food. 

The drug may be given to such persons hypodermically, in the 
dose of yp to -$$ grain (0.0006), or by the mouth in the dose of -§-§ to 
■g 1 -^ grain (0.0008). The fact that it possesses no taste and is small in 



HYPXAL. 313 

bulk renders it readily employed. In some persons it utterly fails, even 
in this particular type of case. In delirium tremens it may cause 
evidences of cerebral congestion and Cheyne-Stokes breathing, but, 
on the other hand, it very commonly aids in combating chronic alco- 
holism when given in very large dose. (See below.) Some patients 
are not quieted by the drug, but pace up and down in a semi-sane 
condition until its action wears off. Such symptoms can generally be 
overcome by using larger doses or, better still, by using with it -^ 
grain of apomorphine. It does badly if the kidneys are diseased. 

Hyoscine has been highly recommended in the treatment of the 
morphine and alcohol habit, and there can be no doubt that it is an 
excellent remedy. The patient must be under complete control and 
should be given enough hyoscine hypodermically to be thoroughly 
under its influence, as much as j^o g ram being given every two hours 
if need be to keep him quiet. Aside from constant quiet muttering 
and the characteristic delirium caused by the drug, no evil effects 
ensue and the patient usually, without much suffering, recovers from 
the effects of the narcotic drug to which he is a slave, and in a good 
general state so far as his nerves are concerned. (See AJcohohj 

Hyoscine is of great value in some cases of spermatorrhea and noc- 
turnal emissions if given in the dose of T ^ r) grain (O.OOOGj at bed-time. 

The drug is contraindicated in the sore throat of scarlet fever, as 
it may cause a sensation of pharyngeal constriction. In the insomnia 
of heart disease with nervousness it may cause sleep, but often fails, 
and is not to be recommended. 

Hyoscine is used by ophthalmic surgeons, and in the eye it is far 
less irritating than atropine. Indeed, it may be considered as being 
distinctly sedative in plastic iritis. Its effects are not, however, so 
lasting as are those of atropine; 4^ grain dropped into the eye in one 
dose produces mydriasis in eighteen minutes and ciliary paralysis in 
twenty-three minutes; this mydriasis lasts about twenty-two hours, 
and the ciliary paralysis about ninety-six hours ( Oliver"). It finds 
its greatest usefulness in the early stages of iritis, when a rapidly 
acting and efficient sedative mydriatic is demanded. Hyoscine is best 
used for this purpose in the strength of 0.2 per cent. (1 : 500) in water. 
This solution may be dropped into the eye every twenty minutes till 
one hour has elapsed. As this use of the drug is slightly painful it 
is well to place a few drops of cocaine solution in the eye before each 
instillation of hyoscine. 

HYPNAL. 

The chemical name of this substance is monochloral-antipyrine, 
and it is, as its name indicates, a compound of chloral and antipyrine. 
There is also a dichloral-antipyrine, which contains more chloral. The 
compound is employed in treating those patients who suffer from 



314 DRUGS. 

both pain and insomnia, the antipyfine relieving the pain and the 
chloral producing sleep. Opium is the only drug known which can 
be relied upon to act in this double manner, and the disadvantages of 
that medicament are often so prominent as to prevent its use. The 
drug has been used in neuralgic insomnia, but for some reason it has 
not proved as popular as was expected when it was introduced. The 
dose is from 5 to 20 grains (0.3-1.3), best given with simple syrup 
and water or with syrup of orange-peel, or it may be used as follows: 

]$ — Hypnal gr. xv (1.0). 

Chartreuse foj (4.0), 

Distilled water f§ss (16.0) — M. 

S. — The entire amount to be taken in one dose. 

Chloral and antipyrine when mixed together usually liquefy. 



ICHTHYOL. 

The substance sold in the shops and employed in medicine under 
the name of ichthyol is a salt formed by the bibasic acid ichthyo- 
sulphuric or sulpho-ichthyolic acid with ammonium. In other words, 
it is ammonium ichthyol, which is a semi-solid substance. The 
ichthyo-sulphuric acid itself is derived from a crude oil, which in 
turn is obtained by destructive distillation from a deposit of fossil fish 
found in the Tyrol Mountains. When combined with sodium, forming 
sodium ichthyol, a more solid substance than ammonium ichthyol is 
formed which can be employed if it is desired to use the drug in pill 
form. Both the ammonium and sodium ichthyol contain about 10 per 
cent, of sulphur, and it is largely upon this that their therapeutic 
activity depends. They are both soluble in water, and have a dark- 
brown, tarry appearance. Their disagreeable odor is due to an in- 
separable volatile oil. The stain produced by ichthyol is easily washed 
out of ordinary clothing except when it is mixed with vaseline, which, 
being insoluble in water, fixes the stain in the fabric. 

Therapeutics. — Ichthyol is, without doubt, one of the most remark- 
able substances introduced for medicinal purposes within the last thirty 
years, both because of its curious origin and its therapeutic value in a 
large variety of ailments. In the author's hands it has proved most 
efficacious in the treatment of the inflamed areas in acute articular 
rheumatism. When used in this disease an ointment composed as fol- 
lows is to be smeared over the inflamed part, and then spread on lint, 
which is wrapped about the limb: 

1^— Ichthyolis §ss (16.0). 

Olei citronellse gtt. xv vel xxx (1.0-2.0). 

Adipis vel adipis lanae hydrosi . . . 5j (30.0). — M. 

This usually relieves the pain and tenderness of the part to a great 
extent. The same application, accompanied by rubbing or applying 



IODIDES OF AMMONIUM AND ETHYL. 315 

massage to the joint, is of value for the pain and stiffness met with 
after the acute manifestations of the disease has passed by, 

The same prescription is also the best external treatment of erysip- 
elas that we have. The skin should be carefully and gently washed, 
and then anointed with the ointment and covered by lint smeared 
with this ointment. If the disease be in the skin of the face, holes are 
to be cut in the lint for the mouth, nose, and eyes. Ichthyol is also a 
very useful drug in the treatment of chronic skin diseases associated 
with atony and induration of the deeper layers of the skin, such as 
acne, eczema, and even lupus and keloid in their chronic stages. It is 
always better to use ichthyol in ointment form, but some practitioners 
have employed it by painting it on in watery solution with a camel's- 
hair brush. In frostbites, chilblains, and in bums it is of service, and 
Agnew recommended it highly when rubbed into lymphatic enlarge- 
ments. Ichthyol has proved remarkably efficacious in removing peri- 
uterine and other pelvic exudations when used as a salve with pelvic 
massage or in a vaginal suppository. 

For acute sprains, and for the removal of the swelling following 
such injuries, its influence is extraordinary if it be well rubbed into 
the part affected. 

In severe cases of cracked nipples, with much induration, an oint- 
ment of ichthyol, 1 to 4 drachms (4.0-16.0) of lanolin, will prove of 
value, but it must be washed off thoroughly before each nursing or 
the child will not take the breast. Often the odor remains and pre- 
vents nursing, 

The dose of ichthyol internally in g astro-intestinal catarrh is 1 to 10 
grains (0.06-0.60), given in pill or capsule. 

Ichthyol is a very useful remedy for the treatment of fetid ozcena. 
(See Nasal Catarrah, Atrophic, Part IV.) 



IODALBIN. 

Iodalbin is a new iodine preparation containing about 20 per cent, 
of iodine, or, in other words, about 56 per cent, less iodine than iodide 
of potassium. It is used for the same purposes as the latter drug. 
Owing to the readiness with which the iodine is absorbed, doses larger 
than those of iodide of potassium are usually not required, or, to express 
it differently, the iodine does not separate from the iodide of potassium, 
sodium, or ammonium as readily as it does from this combination of 
iodine with a proteid. 

The dose is 5 grains (0.3), repeated as frequently as may be needed. 

IODIDES OF AMMONIUM AND ETHYL. 

(See Ammonium Iodide and Ethyl Iodide.) 



316 DRUGS. 

IODIDE OF POTASSIUM. 

Potassium iodide (Potassii lodidum, U. S. and B. P.) should contain 
not less than 99 per cent, of pure potassium iodide, and should be 
kept in well-stoppered bottles. 

It occurs in colorless transparent, translucent, or opaque white, 
cubical crystals, or a white, granular powder, having a peculiar faint, 
iodine-like odor, and a pungent, saline, afterward bitter taste. It is 
permanent in dry air, and but slightly deliquescent in moist air. It 
is soluble in 0.7 part of water, and in about 22 parts of alcohol at 
25° C. (77° F.) ; in 0.5 part of boiling water, and in 8 parts of boiling 
alcohol; and in 2 parts of glycerin. 

The physiological effects of potassium iodide are entirely comparable 
to those of iodine itself (see Iodine), but it is employed for some- 
what different purposes, is less irritant, more readily given, and per- 
haps more readily absorbed. When it is given in very large doses 
or for a long period of time, the fact that the potassium base is a 
depressant poison is to be remembered, and it is well to use iodide 
of sodium instead. 

Physiological Action. Circulation. — Upon this part of the system 
when in health iodide of potassium produces effects differing very 
slightly, if at all, from those caused by potassium itself. Small amounts 
raise the blood-pressure, and large quantities lower it (Prevost and 
Binet), but if spasm and fibrosis of the bloodvessels be present with high 
arterial tension in association with it, iodide of potassium acts as a 
valuable remedy in reducing the vascular spasm. 

Absorption and Elimination. — Iodide of potassium is very rapidly 
absorbed and eliminated, appearing in the urine, according to Doux, in 
thirteen minutes after it is ingested, the daily amount excreted equal- 
ing about SO per cent, of the dose taken. Some of the drug tends to 
accumulate in the body< It is evident, therefore, that in the use of 
iodide of potassium we should give it freely and frequently until 
the residual amount has reached its limit, when smaller doses may be 
given, and given less frequently, for the purpose of maintaining the 
iodine influence. That is to say, the drug should be given up to the 
point of tolerance, whatever that may be, and then a smaller dose will 
be sufficient to maintain its influence by replacing the albuminoid 
compounds of iodine as they are slowly eliminated. On the other 
hand, if the iodide is being given for the purpose of eliminating some 
poison, as lead, for example, here the dose cannot be greatly decreased, 
because in addition to the quantity ordinarily eliminated a portion is 
passed out as a double soluble iodide of lead. This theoretical deduc- 
tion seems to find support in the fact that after the syphilographer 
reaches the full effect of the drug he often cuts the dose down to what 
he calls the " tonic dose," and so maintains the constant alterative effect 
without disordering the functions of the body. If he does not do this, 
the drug accumulates and causes chronic iodine cachexia, a state which 



IODIDE OF POTASSIUM. 317 

it is important to avoid in grave diseases like syphilis, which depend 
for their relief so largely on the maintenance of vitality in the patient. 

All traces of the iodine in the urine disappear four or five days after 
the last dose is administered (Elhers). 

Therapeutics. — The medicinal uses of iodide of potassium may be 
divided into three great divisions, each of which is important. It is also 
employed for many conditions not included in these classes: 

1. Syphilis. — The use of iodide of potassium in syphilis is recog- 
nized as a part of all treatment for its relief. Elsewhere, Dr. Martin 
has, in his excellent article (see Syphilis), treated of this question, and 
it is only necessary to call attention to the fact that the drug is generally 
well borne in large amounts by advanced syphilitics, although this is 
not always the case. The term " therapeutic test" is applied by one 
eminent teacher to signify a state of the system produced by syphilis in 
which a diagnosis may be made by the fact that large doses of the iodide 
are borne without inconvenience. This resistance does not always 
prove the presence of syphilis, nor does the absence of this resistance 
prove the absence of this disease. Persons having hereditary asthma, 
gout, rheumatism, or some similar diathetic malady often resist the 
iodide, and, on the other hand, some syphilitics exhibit "iodism" after 
very small doses. In treating late syphilis the drug should be used in the 
dose of 10 grains (0.60) three times a day, and this amount gradually 
increased a grain a day until symptoms of "iodism" occur. 

It is well to bear in mind that non-syphilitic persons who are 
taking, or have recently taken, iodides often give a positive reaction 
to the luetin test. 

The quantity borne often amounts to from 100 to 200 grains (6.6- 
13.2) a day, and as much as 400 grains may be taken by some persons. 
The best way to use the iodide of potassium is to order for the patient 
a saturated solution of the drug, which contains in each drop about 
1 grain, and at the same time a bottle of the compound syrup of 
sarsaparilla. To a tablespoonful of the latter the patient is to add the 
iodide solution, beginning with 10 minims (0.60) three times a day, 
and increasing a minim every twenty-four hours. 

The iodide acts more slowly as an antisyphilitic than does mer- 
cury. 

In tertiary syphilis the iodide is often valuable rather to hold the 
pathological process in check than to affect the specific cause. 

In nervous syphilis, be its manifestations what they may, iodide of 
potassium is a standard remedy, but mercury and salvarsan are more 
•active and useful. It is not curative in sclerotic post-syphilitic 
changes nor in locomotor ataxia due to syphilis, except in the earliest 
stages, because destroyed cells cannot be restored, but it can be 
used to arrest further advance of the results of the disease. It may 
greatly improve the patient's condition by preserving cells not as yet 
entirely destroyed. 

The therapeutic effect of this drug is much increased if hot vapor 
baths are used simultaneously with its internal administration. 



318 DRUGS. 

2. Metallic Poisoning. — Owing to the fact that iodide of potas- 
sium forms soluble double salts with all the metals in the tissues in 
chronic poisoning, thereby aiding in their elimination, it should always 
be employed in chronic lead, zinc, arsenic, or mercurial poisoning. 

3. Antirheumatic. — Iodide of potassium is best suited, not to 
acute articular rheumatism, when the joints are very hot and painful, 
but to the secondary or subacute types, when the joints are enlarged 
and the case " hangs on" — now better, now worse. It acts best, under 
these circumstances, if combined with wine of colchicum-seed. (See 
Rheumatism.) It is also to be tried in sciatica, lumbago, and rheumatic 
neuralgia, and it may be employed in chronic pleurisy, pericarditis, 
and hydrocephalus to cause absorption of the fluids. In these con- 
ditions, however, it often fails and cannot be relied upon. 

In aneurism, particularly that of the aorta, the drug often does good, 
but its value rests largely upon the cause of the disease. If it is due to 
syphilis, the aneurism may cease to grow under its influence, and the 
pain, swelling, and pulsation gradually decrease. 

In asthma iodide of potassium is valuable if the disease is of the pure 
bronchial or lithsemic type, but it ought not to be employed if the cause is 
associated with gastric irritation or indigestion, as it makes the condition 
of the stomach worse. In bronchitis and intestinal catarrh where the 
condition of the mucous membranes is semi-chronic, and not relieved 
by chloride of ammonium, iodide of potassium should be used. If the 
bronchitis is chronic and the secretion profuse (bronchorrhcea) , iodide 
of potassium will make it worse. The dose for an adult in all these 
instances should be about 3 to 5 grains (0.20-0.3) three times a day, 
for small doses tend to increase secretion far more than large ones, 
which often seem to decrease it. In pulmonary emphysema iodide of 
potassium is often of great value chiefly because it benefits the asso- 
ciated chronic bronchitis. 

In chronic interstitial nephritis small doses (5 grains [0.3] t. i. d.) 
are thought by some to check the disease, but it is to be remembered 
that the drug may produce untoward symptoms if the kidneys do not 
eliminate it, so that, if used at all, it must be given with great care. If 
the drug is well borne in chronic parenchymatous nephritis, it will 
cause an extraordinary increase in the urinary flow, and will often 
relieve very rapidly any dropsy which may be present. 

In bronchocele the employment of iodide of potassium internally and 
tincture of iodine externally is the best treatment we can use, and in 
acute coryza, or "cold in the head," 10 grains (0.60) taken at the begin- 
ning of the trouble will often abort the attack. 

In hepatic cirrhosis, in its early stages, the iodide often does good 
in arresting the overgrowth of connective tissue, and in arteriosclerosis 
or atheroma of the bloodvessels it is of great service. Thus in the 
latter conditions a combination of iodide of sodium or potassium with 
a little digitalis will relieve vascular spasm and support a feeble heart. 

A very important use of iodide of potassium is for the removal of 



IODIDE OF POTASSIUM. 319 

enlargements of the cervical glands and those occurring in other parts 
of the body. Full doses are useful in actinomycosis. In the later 
stages of pneumonia the iodides are sometimes useful to aid in the 
absorption of the exudate, but they are contraindicated in phthisis, 
except in the fibroid form and except in those cases which are dependent 
upon syphilis as an underlying dyscrasia, as they aid in the breaking 
down of the lung. 

Untoward Effects. — In some persons, after the use of the iodide, 
coryza comes on, so that the edges of the eyelids become reddened 
and the nose runs constantly; and it is a curious fact that small 
doses are more apt to produce such a result than large ones. This is 
followed, if the drug is freely given, by the more positive signs of 
"iodism" spoken of under Iodine. 

In other cases acne breaks out on the face and disorders of digestion 
and gastric irritability come on. The acne can nearly always be pre- 
vented by giving arsenic at the same time with the iodide. In some 
cases petechial rashes break out on the legs, while in others great 
mental and physical depression appears, so that listlessness or melan- 
cholia may develop. Sometimes iodide of potassium causes diarrhoea. 

In persons susceptible to iodide of potassium care should be exer- 
cised when it is first administered lest sudden and dangerous oedema 
of the glottis occur. Eisner has reported a case in which death due 
to this cause followed the administration of 30 grains of the iodide 
of potassium. Multiple hemorrhages from the skin and mucous 
membrane occurred. 

If bulke or blebs follow the use of the iodides or other rashes appear, 
it is said that atropine will afford relief. 

Sometimes the iodide of ammonium or iodide of sodium or iodide 
of strontium will be borne when the iodide of potassium will not. 

The hydrochloric acid and chloroform test for indoxyl sulphate of 
potassium in the urine is useless if the patient is taking iodides. 

Administration.- — The iodide of potassium, owing to its exceed- 
ingly disagreeable taste, should be given with the compound syrup 
of sarsaparilla, as already described, with fluidextract of liquorice, or 
in milk. Large amounts of these vehicles are to be used. A good way 
to give it is to add the drug to one of the liquid pepsins, and then to add 
this to warm milk, as in the directions for the preparations of junket 
given in Part III. The curd largely disguises the taste of the drug. 
The dose usually varies from 5 to 60 grains (0.30-4.0) three times a 
day, according to the condition of the patient. It is best given an 
hour after meals, so that it will not disorder digestion by irritating 
the stomach or interfere with the action of the gastric juice. 

One of the best ways to take the drug is in capsule, but if this is done 
a drink of milk or water or other fluid should precede or follow it, in 
order to prevent the drug from coming in contact with the stomach in 
concentrated form. 



320 DRUGS. 

IODIDE OF SODIUM. 

Sodii Iodidum, U. S. and B. P., is used in the same doses and for the 
same purposes as the iodide of potassium, and is less irritant than the 
latter salt, as well as less depressant to the general system. 

IODIDE OF STRONTIUM. 

Iodide of strontium (Strontii Iodidum, U. S.) is used as a substitute 
for iodide of potassium, as it is less irritating to the stomach and less 
depressing to the general system. (See Strontium.) 

IODINE. 

Iodum, S. S. and B. P., is a non-metallic element found largely in 
seaweed and in mineral iodates and iodides. It should contain not 
less than 99 per cent, of pure iodine, and be kept in glass-stoppered 
bottles, in a cool place. It occurs as heavy, bluish-black, dry and 
friable, rhombic plates, having a metallic lustre, a distinctive odor, and 
a sharp and acrid taste. 

Iodine imparts a deep brown, evanescent stain to the skin, and 
slowly destroys vegetable colors. It is soluble in about 2950 parts of 
water, and in 12.2 parts of alcohol at 25° C. (77° F.). It is freely 
soluble in ether, chloroform, or carbon disulphide ; its solution in alco- 
hol or in an aqueous solution of potassium iodide has a reddish color; 
its solution in chloroform or carbon disulphide has a violet color. 

It volatilizes slowly at ordinary temperatures. 

Physiological Action. — The physiological action of iodine, so far as 
its alterative powers are concerned, is absolutely unknown. Applied 
to the skin, it stains it yellow, brown, or black according to the free- 
dom of its application, and it acts without pain if the skin is intact. 
If very large amounts are used, it produces vesication. Upon mucous 
membranes iodine acts as a powerful irritant. Germain-See believed 
it to be a stimulant to the nutritive processes of the body and to the 
circulatory system, and he was certainly correct in regard to the influ- 
ence it exercises over nutrition. 

Absorption and Elimination. — The drug is rapidly absorbed, 
escapes from the body chiefly through the kidneys, the skin, the salivary 
glands, and it even appears in the milk of nursing women to such an 
extent that the nursing infant may be affected by iodism and suffer 
from gastro-intestinal disturbance in consequence of ingesting it. 

Poisoning. — The symptoms of acute poisoning by iodine are those 
of acute gastro-enteritis, such as severe pain in the oesophagus, stomach, 
and abdomen, accompanied by violent vomiting and purging. An 
early symptom is the persistent strong metallic taste in the mouth, 
with markedly increased salivation. The pulse becomes rapid, run- 
ning, and feeble, the face deathly pale, total arrest of urinary secretion 



IODINE. 321 

takes place through renal irritation, and death occurs by failure of 
respiration, which is accompanied by loss of all vital power. 

If the poisoning is not severe enough to cause death at once, a fatal 
result is, nevertheless reached after a few days by reason of the severe 
gastro-enteritis and the widespread fatty degeneration of the tissues 
which iodine produces. 

The treatment of the poisoning consists in the use of large amounts of 
starch in any of its forms as the antidote, the employment of emetics 
and the stomach-pump, the application of heat to the body and extrem- 
ities, and, finally, the employment of hypodermic injections of alcohol, 
digitalis, and atropine or strychnine for the purpose of maintaining the 
strength of the circulatory and respiratory systems. 

Untoward Effects. — Under the name of "iodism" the profession 
recognizes a state of the body brought on by the prolonged and excessive 
use of iodine in any of its forms. The earliest notable signs of this 
state are a peculiar metallic taste in the mouth, particularly in the 
morning, slight tenderness of the teeth and gums, increase of salivary 
secretion, a little morning nausea, a lack of appetite for breakfast, 
and perhaps some coryza or evidence of gastric irritation. Acne 
rosacea often comes on very early during the use of full doses of iodine. 
If the drug is continued, all these symptoms become more marked and 
the coryza becomes intense. Frontal headache and sore throat often 
appear, and the pustular and bleb-like changes in the skin go on to 
active suppuration. Sometimes large boils appear or purpura hsemor- 
rhagica (iodic purpura) comes on. Slight catarrhal fever may develop. 

In other cases the nervous system chiefly suffers. Twitchings of 
muscles, neuralgic pains in the trunk and extremities, and wasting of 
the testicles, mamma?, and all other tissues occur as the result of trophic 
disturbances. Ansemia amounting to an actual cachexia is next pro- 
duced. Loss of vision and paralysis may ensue* in extreme cases. 
Soullier asserts that albuminuria may be developed in children after 
tincture of iodine has been freely applied to the skin, by reason of its 
absorption and irritation of the kidneys. 

Therapeutics.— In all cases where the glandular system is in a state 
of chronic perverted functional activity, as in those diseases associated 
with disorder of the processes of nutrition, and often included under 
the single name of scrofulosis, iodine is of service unless there is active 
tissue break-down. In enlargement of the lymph nodes it is one of the 
best remedies we possess, but it ought not to be employed in those cases 
where rapid changes are going on in the gland, such as the formation of 
pus, since under these circumstances it will increase the size of the 
slough. Neither will it benefit the glandular enlargements of Hodg- 
kin's disease or lymphatic leukaemia. The drug ought never to be used 
in acute pulmonary tuberculosis, because it tends to disintegrate the 
tissues, and this is precisely what the disease is doing. In the exceed- 
ingly chronic form of pulmonary disease known as fibroid phthisis iodine 
may often be used with advantage. When inhaled as vapor it may be 
of service as a stimulant to the mucous membranes, but is never of 

21 



322 DRUGS. 

value in phthisis so far as combating the true pathological change i-s 
concerned. In countries where goitre is very prevalent iodine ranks as 
a most efficient remedy, but it must be used with caution, and in case of 
exophthalmic goitre it is probably harmful in that the hypertrophied 
gland probably produces some of its symptoms by excreting too much 
iodine. In cystic or vascular enlargement of the thyroid gland it is 
valueless, but in simple overgrowth of the connective tissue of the 
gland, iodine is of some value. Sometimes it is injected by means of a 
hypodermic needle into the gland. The usual dose is 10 to 15 minims 
(0.6-1.0) of the tincture every second or third day till twenty or 
more injections have been used. Meltzer states that while this treat- 
ment is sometimes efficacious, it is not devoid of danger, for at least 
thirty deaths have resulted from it. 

In chronic bone disease iodine applied about the affected joint in the 
form of the ointment diluted one-half with lard, or in the pure tincture 
will be found of service, and if anosmia exists the syrup of the iodide 
of iron should be given internally. 

The other external uses of iodine are many and important. As a 
slow counterirritant, which does not produce pain if properly employed, 
it is particularly useful in children, and may be employed in one to three 
coats, and no more, applied by means of a earner s-hair brush. 

The proper way to use the tincture of iodine as a local counter- 
irritant for adults is to give one good black coat at one sitting and not to 
repeat it until the skin has desquamated and become well renewed. If 
iodine is applied after desquamation of the skin has begun, it will cause 
agonizing burning pain, which nothing will relieve except the removal 
of the iodine by the use of cologne-water, alcohol, whisky, or gin. 
The application of any of these liquids causes such an increase in the 
pain as to be almost useless after the skin is broken. The best solution 
for its removal is ofle of iodide of potassium, which should be followed 
by a starch poultice. A good rule to follow is never to cause pain by 
the use of iodine, as the drug acts equally well if applied in such a way 
as to avoid suffering. 

A stronger and more active preparation of iodine in solution for 
external use is that suggested by Elsberg. This preparation is of 
20 per cent, strength, whereas the ordinary tincture is 7 per cent. 
It is composed of iodine, 5 drachms (20.0); alcohol and ether, of 
each, 10 drachms (40.0). One or two coats of this solution painted 
upon the skin will produce as much effect as several of the ordinary 
tinctures, and as it dries rapidly it does not soil the clothing. 

In harassing, irritative cough tincture of iodine may be painted over 
the supraclavicular spaces, and it will sometimes lessen the secretion in 
chronic bronchitis if used in this way. In chronic rheumatism affecting 
the joints and muscles it does good when locally applied. Often in 
synovitis the local application of iodine, provided the skin is not in- 
flamed, causes increased swelling for some days. This should not cause 
alarm, for ultimately the swelling decreases greatly, and the cases in 



IODINE. 323 

which this occurs are generally the best from a prognostic point of 
view. 

In the course of phthisis every now and then a "spot" in the chest 
will become "sore," probably due to a limited area of pleurisy, and 
under these circumstances tincture of iodine locally applied will give 
relief. In lupus the tincture may be painted around the edges of the 
growth, and even over its surface, with the object of retarding its 
spread. In chilblains an application of iodine ointment gives the 
greatest relief if diluted one-half with lard, and its use is probably the 
most efficacious measure at our disposal. In certain individuals who 
have " pains in the chest" iodine ointment may do good if rubbed in 
over the affected spot. As has been pointed out by others, iodine does 
good if muscular tenderness is present, while it fails if pleurodynia or 
intercostal neuralgia is the cause of the suffering. The latter troubles 
should be removed by the use of belladonna. In certain forms of skin 
diseases, such as tinea tonsurans and circinata, tincture of iodine may 
be applied with a camePs-hair brush, and even the entire scalp may be 
painted. A better way is to apply it to different spots each day. When 
erysipelas is present, the tincture may be painted around the edges of 
the inflamed area in order to prevent its spread. 

Tincture of iodine is a useful application to heal leg ulcers, painting 
it over and around the lesion. 

Within recent years tincture of iodine, in the form of the official 
tincture, or, more commonly, in 2 per cent, solution in ethyl alcohol, 
has been largely and successfully employed to sterilize the skin at the 
site of operative procedures. In scalp wounds, or wounds of other 
hairy parts, and in wounds filled with dirt, as in the case of crushed 
fingers or toes, the parts should be thoroughly painted and swabbed 
with tincture of iodine, and no other antisepsis is required. Washing 
the parts with water before using the iodine is unwise, as the water 
swells the cells and prevents the iodine from acting as a penetrating 
antiseptic. The surgeon can also sterilize his hands by dipping them 
in 2 per cent, iodine, and they may be largely decolorized afterward by 
washing them in a solution of boiled starch, hydrogen peroxide, or am- 
monia water, or a 3 per cent, carbolic acid solution. 

In old persons or those in middle life retraction of the gums from the 
teeth sometimes comes on with fetid breath. This can be greatly 
relieved or cured by rinsing the mouth twice daily with 5 drops (0.30) 
of tincture of iodine in 2 ounces (60.0) of water. 

In hydrocele iodine in the form of the tincture is one of the best drugs 
for effecting a permanent cure. The sac should first be emptied by the 
use of a trocar and canula, and the iodine alone, or mixed with glycerin, 
injected with a syringe and then allowed to escape. As the pain 
produced by this injection is most atrocious, the patient should first 
be put under the influence of ether or some other anaesthetic. 

Injections of iodine have been made into various serous cavities for 
the relief of chronic inflammatory processes. This is sometimes fol- 



324 DRUGS. 

lowed by unfavorable symptoms, and after the injection of tincture of 
iodine into the pleural cavity in hydrothorax symptoms of poisoning 
have come on in some cases, the most common complication being 
convulsions. These are epileptiform in character and are followed 
by coma or collapse. 

In empyema a solution of iodine 6 grains (0.40), iodide of potassium 
6 grains (0.40), and water 1 pint (480 mils.) may be used daily as an 
irrigating fluid with good results; but this practice is not entirely 
devoid of danger, as too much of the iodine may be absorbed or the 
irritation produced in the chest by its injection may cause reflex and 
severe nervous symptoms. Iodoform is better for this purpose, but for 
suppurating sinuses a 1 per cent, solution of iodine may be employed. 

The tincture of iodine may be used, according to Ringer, as an 
inhalation with signal benefit in the following three instances: 

1. In the chronic forms of phthisis (fibroid lung). When the expec- 
toration is abundant and when the cough is troublesome, its inhalation, 
used both night and morning, will generally lessen expectoration and 
allay the cough. 

2. In children six to ten years of age, who after meals, or, inde- 
pendently of them, on exposure to cold, are seized with hoarseness, a 
hoarse, hollow cough and some wheezing in the chest. This affection , 
involving the larynx, trachea, and larger bronchial tubes, and often 
proving very obstinate, is apt to return and to persist for some time. 

3. Some persons suffer with itching of the nose, of the inner can thus 
of one or both eyes, sneezing, running at the nose, of a watery fluid, 
weeping of the eyes, and severe frontal headaches; and these patients of 
various ages are greatly troubled, often for many years, with daily 
attacks of this character, lasting, it may be, several hours. Iodine 
inhaled often relieves this affection at once, lessening the headache 
and discharge from the nostrils. Its effect is most marked in respect 
to the itching. 

Ringer generally adopts the following simple, handy, cleanly, and 
effectual plan of inhalation: Heat well a jug capable of holding about 
2 pints by rinsing with boiling water; then partly fill with boiling 
water, into which pour 20 to 30 minims (1.3-2.0) of the tincture 
of iodine; then direct the patient to put his face over the mouth of 
the jug and breathe the iodized steam, covering the head to prevent 
escape of the vapor. This inhalation should be used night and morn- 
ing for five minutes or a little longer. Occasionally an excess of iodine 
will temporarily produce a sensation of soreness in the chest and 
throat, accompanied with redness of the conjunctiva, running from 
the nose, and pain in the head. 

In some cases of acute coryza much relief may be obtained by sniffing 
the fumes of tincture of iodine from a bottle, as in the use of " smelling 
salts." The heat of the hand is sufficient to disengpp^ the vapor in 
proper quantity. 

A useful gargle in cases of relaxed sore throat is as follows: 



IODOFORM. 325 

3— Tincturae iodi f3J (4.0). 

Potassii iodidi 5J (4.0). 

Spiritus vini gallici foj (30.0). 

Aquae destillatse q. s. ad fgiv (120.0). — M. 

S. — Use 2 teaspoonfuls (8.0) in half a glass of water as a gargle three times a day. 

An alcoholic solution of iodine of the strength of one-half of 1 per cent, 
is an efficient disinfectant for the hands. The color can be removed by 
rinsing with dilute ammonia water. 

Administration. — Iodine is never used in solid form, and it has 
been taught that the tincture (Tinctura Iodi, U. S., and Tinctura Iodi 
Mitis, B. P.) should not be given internally, on the ground that it is 
precipitated in the stomach. Whether this be true or false, it is a 
fact that the tincture has been largely used in the vomiting of preg- 
nancy and that occurring after the use of anaesthetics with very good 
results. The dose is 5 to 10 minims (0.30-0.60), 2 to 5 minims (0.12- 
0.3), B. P., well diluted. Under the name of Lugol's solution (Liquor 
Iodi Com posit us f U. S.) iodine is frequently used internally as an 
alterative and substitute for iodide of potassium; the dose is 5 to 10 
minims (0.30-0.60), in water. Tinctura Iodi Fortis, B. P., is used 
as a local application. 

Unguentum Iodi, U. S. and B. P., is used locally over enlarged glands. 
In the case of children or adults who have delicate skins the ointment 
should be diluted one-half- with lard. This ointment should always be 
freshly made. 

Contraindications. — Iodfne when given internally is contraindicated 
in renal diseases, except in small doses, during the progress of acute in- 
flammation, and whenever tissues are rapidly undergoing a breaking- 
down process. 

IODOFORM. 

Iodoform (lodoformum, U. S. and B. P.) occurs in a fine lemon- 
yellow powder or lustrous crystals of the hexagonal system, having a 
peculiar, very penetrating, and persistent odor, and an unpleasant, 
slightly sweetish, and iodine-like taste. It is soluble in 9391 parts of 
water, to which it imparts its odor and taste, in 60 parts of alcohol 
and in 7.5 parts of ether at 25° C. (77° F.) ; in about 16 parts of boiling 
alcohol; in chloroform and fixed and volatile oils; and is slightly soluble 
in petroleum benzin. 

Physiological Action. — The effects of iodoform upon the circulation, 
respiration, and other vital functions are very slight when the drug is 
used as a surgical dressing in ordinary amounts or when it is given by 
the mouth in average doses. It acts as an anaesthetic upon mucous 
membranes, and produces those changes which we are wont, for want 
of a better term, to call " alterative," in the tissues with which it comes 
in contact. Iodoform is eliminated in the urine as iodine or as alkaline 
iodides, chiefly as iodide of sodium. The drug also escapes by the saliva 
as an alkaline iodide. 



326 DRUGS. 

Poisoning. — If applied to an absorbing surface in susceptible indi- 
viduals, iodoform may cause general systemic poisoning. This poison- 
ing may be mild, in which case there is a general feeling of malaise, 
with nausea and the perception of various odors which are in reality not 
present. There may be headache and vomiting. If the system is still 
more impressed by the drug, these symptoms are followed by cerebral 
excitement, insomnia, loss of memory, loss of appetite, and a rapid 
pulse. In grave cases convulsive movements and maniacal delirium, 
alternating with coma, may be the dominant symptoms. The pulse is 
small and rapid, and there is often retention of urine or hematuria. 
Loebisch asserts that the mental excitement cannot be quieted by 
narcotics. If death occurs, the heart and respiration fail simultane- 
ously. In addition to the fatty degeneration which such poisoning pro- 
duces in all the vital organs, there is sometimes found an cedematous 
condition of the pia mater or a low-grade leptomeningitis. These 
symptoms seem to occur more commonly in the aged. In the graver 
cases the onset of the poisoning is apt to be sudden, though from 
twenty-four hours to several days usually elapse between the applica- 
tion of the drug and the onset of the symptoms of poisoning. 

Treatment of the poisoning by iodoform consists, according to 
Soullier, in the administration of bicarbonate of sodium to unite with 
the iodine and so aid in its elimination; the use of alcoholic stimulants 
to support the system; the employment of diuretics, and wrapping the 
patient in hot blankets to encourage free sweating, so relieving the 
kidneys. Kocher advises saline transfusion in such cases. 

Untoward Effects. — It is not to be forgotten that iodoform when 
applied as a dressing may produce less violent symptoms than those 
just described. Sometimes a scarlatinal rash may develop with fever, 
malaise, and nervous disturbances. 

Therapeutics. — Iodoform is used chiefly as a surgical dressing, but 
is by no means so popular for this purpose as it was at one time. It is 
antiseptic, but not germicidal. Germs may be found in powdered 
iodoform, and will even grow in it. When used locally, the drug does 
good by absorbing the liquids of the wound, and thereby removing the 
nidus for germ-growth, and when applied to large moist surfaces gives 
off free iodine and acts as well as a protective. There can be no doubt 
that iodoform when applied to a wound does good, not by destroying 
the bacteria directly or indirectly, but by inducing chemical changes 
in their toxins. 

In syphilitic sores the following dressing will be found of great 
service: Iodoform, 20 grains (1.3); oil of eucalyptus, \ fluidounce 
(16.0); or a powder of iodoform \ ounce (16.0), camphor 75 grains 
(5.0), and essence of rose 2 drops (0.1), may be employed. In eczema, 
with tingling and itching, the following application will give relief 
(Ringer) : 

1^— Iodoformi . . . ' . . . . . gr. iv (0.25). 

Olei eucalypti ....... f5j (4.0). 

Petrolati \ ........ 5j (30.0).— M. 

S. — Apply locally. 



IODOL. 327 

Internally, iodoform is used in tertiary syphilis in all its forms in the 
dose of from 1 to 5 grains (0.6-0.3). Bartholow has recommended 
it most highly in catarrhal jaundice and in the early stages of hepatic 
cirrhosis. 

The influence of iodoform upon the tubercle bacillus is very great, 
and it is largely used in the treatment of tubercular disease of the 
joints and pleura 3 . The pus is allowed to escape under antiseptic pre- 
cautions; the cavity is washed out with warm boric-acid or phenol 
solutions of low strength, and from 1 to 6 drachms (4.0-24.0) of an 
emulsion of iodoform and sterilized sweet oil are injected and allowed 
to remain. The strength of the iodoform-and-oil emulsion should 
usually be 10 per cent. Should the abscess cavity fail to heal after 
these injections have been repeated every few days for some time, it 
must be reopened, scraped, and injected again or packed with iodoform 
gauze. The iodoform also promotes healing through its alterative 
influence, which aids in the absorption of the inflammatory exudate. 
Should tubercular glands be present, injections may be made into them 
even if pus has not formed. 

Used by means of a powder-blower, iodoform will often relieve the 
hoarseness and discomfort of laryngeal phthisis, but it must be pulver- 
ized most minutely. Sometimes a spray may be used, which should 
consist of spirit of turpentine and sweet oil, half-and-half, and con- 
tain 2 grains (0.12) of iodoform to each ounce (30.0). This mixture 
may also be used in chronic bronchial catarrh to lessen the cough and 
fetid discharge. In the early stages of phthisis several clinicians claim 
to have obtained good results by the daily hypodermic injection into 
the back of 30 minims (2.0) of a 1 : 100 solution of iodoform in oil of 
sweet almonds, but this treatment has not found favor, in the United 
States at least. 

For fissure of the anus and irritated hemorrhoids 5 grains (0.30) of 
iodoform in a suppository may be placed in the rectum, and after it. 
has remained there a few minutes defecation may take place with little 
or no pain. The pain following operations on the female perineum 
may also be much relieved in this manner. In the rectal tenesmus of 
cholera infantum an injection of 1 ounce (30.0) of sweet oil with 5 
grains (0.30) of iodoform will give great relief if used after or before 
enteroclysis. 

Administration. — The ointment of iodoform (Unguentum lodoformi, 
U. S. and B. P.) is useful when applied over fetid sores. It should 
always be freshly made. The drug itself may be given in 1- to 5-grain 
(0.06-0.30) doses three times a day. The suppositories (Suppositoria 
lodoformi) are otflcial in the B. P.; each one contains 3 grains (0.20) 
of iodoform. (See also Xosophen, Europhen, and Thymol Iodide.) 

IODOL. 

Iodol is a light grayish-brown, crystalline powder, without odor 
or taste. It is soluble in about 4900 parts of water, 9 parts of alcohol, 



328 DRUGS 

1.5 parts of ether, 105 parts of chloroform at 25° C. (77° F.), and 
in fixed oils. It is also soluble in concentrated sulphuric acid, produc- 
ing a green solution gradually changing to brown. It should be 
kept in amber-colored bottles. Its uses in medicine are identical 
with those of iodoform, and it possesses the advantage of having a 
less penetrating odor than the latter drug. 

In tubercular laryngitis the very finely powdered drug may be blown 
into the larynx without disagreeable results and with a favorable 
effect on the disease process. Cerna has found iodol of great service in 
diabetes when given internally in the dose of from 2 to 6 grains (0.12- 
(0.40) three times a day, and it is said to be of value in tertiary syphilis 
in the same quantity. 

A useful antiseptic dressing for small wounds and abrasions is 
made by adding 1 part of iodol to 10 parts of ether and 5 of gun-cotton, 
thereby preparing an iodol collodion. 

Ingalls recommends the following prescription in cases of eczema or 
abrasions of the upper lip and nostrils: 

I$— Phenolis ITLv (0.3). 

Olei rosse iflv (0.3). 

Iodoli gr. xxv (1.6). 

Adipis lanse §ss (16.0). — M. 

IPECACUANHA. 

Ipecacuanha, U. S., or Ipecacuanha? Radix, B. P., or ipecac, is the 
root of Cephaelis ipecacuanha (Psychotria ipecacuanha, B. P.), a 
small shrub of Brazil yielding, when assayed by the U. S. P. process, 
not less than 1.75 per cent, of ipecac alkaloids; by the B. P. process, 
2 per cent. It contains the alkaloids, emetine (EmetincB hydrochloridum, 
U. S.), cephaeline and psychotrine. Only emetine is used in medicine. 

Physiological Action. — Locally applied to mucous membranes, ipecac 
acts as an irritant, and if applied for a long period to the skin pro- 
duces vesicles and irritation. Very minute doses have little notice- 
able effect, but large ones produce nausea, relaxation, vomiting, free 
secretion into the bronchial tubes, and a profuse flow of saliva. The 
emesis has been^thought to be due both to the irritation of the stomach 
and to an effect upon the vomiting centre in the medulla (Fig. 51), 
but the large doses of emetine now used by the hypodermic needle 
in the treatment of amoebic dysentery without producing vomiting 
would seem to prove that ipecac given by the stomach acts on that 
organ directly. Ipecac is eliminated by the kidneys, the gastro- 
intestinal mucous membrane, and the skin (Binz). 

If emetine is given in lethal dose to one of the lower animals, death 
is due to failure of respiration, but when it is given by a vein it acts 
as a powerful cardiac depressant as well. For this reason, if emetine 
is given intravenously, it should be put in 100 mils, of normal salt 
solution and injected slowly. 



IPECACUANHA 



329 



Therapeutics. — Ipecac is used as an emetic where a fairly rapid 
action is required. It is particularly useful where the stomach of a 
child is overloaded with food. In cases of poisoning it is hardly 
active or rapid enough as an emetic, and is not so good as mustard or 
sulphate of zinc. In babies and young children an attack of bronchitis 
often causes digestive disorders by reason of the mucus coughed up 
from the lungs being at once swallowed instead of spat out of the mouth. 
In these cases the stomach may be relieved and the state of the lungs 
improved by the use of an emetic dose of syrup of ipecac, 2 to 3 drachms 
(8.0-12.0). Often if this dose be not large enough to produce emesis it 
w ill purge the child and remove the mucus by the bowel. 

In some cases of obstinate vomiting small doses of ipecac will act as 
a most successful cure, provided that the vomiting is due not to inflam- 
mation and excitement, but to depression. The proper dose of ipecac 
for this purpose is J to J grain (0.008-0.015) or less every half-hour 
until five or six doses are taken. 

In some cases of the vomiting of pregnancy it is useful, in toxic cases 
it utterly fails; 1 minim (0.06) of the wine orJ| to i grain (0.008-0.015) 
of the powdered ipecac, repeated every half-hour for six or seven doses, 
is all that should be used. In 

the morning vomiting of drunk- FlQ * 51 " 

ards ipecac is of service, but it 
is not as good a remedy as are 
small amounts of arsenic or 
hydrochloric acid. 

In true amoebic dysentery ipe- 
cac, or its alkaloid emetine, is 
the best remedy we possess. 
When the disease is malignant, 
as it occurs in the tropics, ipe- 
cac should be given in the fol- 
lowing manner : The ipecac is 
to be given on an empty stom- 
ach in the dose of 30 grains 
(2.0) in freshly made pills of 
5 grains (0.35), coated with 
salol or keratin, so that the ipe- 
cac will not irritate the stom- 
ach, but be dissolved in the 

bowel. When this causes vomiting it may be preceded one hour by 
30 minims (2.0) of tincture of deodorized opium, or 20 grains of chloral, 
which is used to decrease the tendency to vomit. This dose should be 
repeated every night for three or four nights, and, in severe cases, for 
a week or more. Absolute rest in bed for two weeks is essential for success. 
Finally, a profuse gray, mushy stool is passed. The passage of this 
stool is a most favorable prognostic sign, and its non-appearance is 
equally significant of failure. There now occurs a decrease in pain and a 




A, vomiting centre in the medulla said to be 
stimulated by ipecac; B, nerves in mucous mem- 
brane of stomach irritated by ipecac. 



330 DRUGS 

lessening of the fever and of bloody discharges. Retching, vomiting, 
delirium, and exhaustion do not contraindicate this plan of treatment, 
If the first dose is rejected, it may be repeated in a few hours, preceding 
it by the laudanum. Counterirritation is to be applied to the belly, and 
stimulants freely used to combat great depression. It is asserted by 
Rogers and many others that, if this plan of treatment is used in the 
early stages of amoebic dysentery and hepatitis, hepatic abscess can be 
prevented in 90 per cent, of the cases. Rogers gives 30 grains (2.0) 
daily for a period of two or three weeks in such cases. If an abscess 
has formed, it must be evacuated by puncture, injected with quinine solu- 
tion, and the ipecac continued. Vedder, of the U. S. Army, has proved 
that the emetine in ipecac is destructive to the amoeba dysenteric, and 
more recently Rogers has shown that the dose of ipecacuanha named 
above can be efficiently substituted by the intramuscular injection once 
or twice a day of J to | grain (0.03-0.04) of emetine hydrochloride 
dissolved in 30 minims (2.0) of normal salt solution. By this means 
nausea and vomiting are avoided and a cure is effected in about half 
the time. Such doses can now be obtained already prepared in sterile 
ampoules, or if need be the solution can be boiled before it is used. 
In obstinate cases both emetine intramuscularly and ipecac by the 
mouth are to be resorted to, cleansing the bowel first with a saline 
purge. Excessive diarrhoea is to be controlled by paregoric. A cure 
is not produced until the stools fail to show the Entamoeba? histolytica. 
Usually a course of at least fifteen days is required, but after the first 
seven days, an interval of seven days' rest should be allowed. In 
severe cases the emetine hydrochloride should be diluted with normal 
salt solution and given very slowly intravenously, particularly in the 
stage of onset. 

In choleraic diarrhoeas and cholera morbus ipecac is said to be of 
service in the dose of 3 grains (0.20) every two hours if opium is given 
to control nausea. 

No less a person than Trousseau asserted that ipecac was a haemo- 
static, and it is said to be a most effective remedy in small doses in 
haemoptysis, and in all hemorrhages which are capillary in character, 
but the manner of its action is obscure. 

^ Ipecac may be used in the early stages of bronchitis, to act as a seda- 
tive to the inflamed mucous membrane and to promote secretion. 
Under these circumstances it is best combined with citrate of potas- 
sium. (See Bronchitis.) 

Ringer and Murrell have found that inhaling ipecac spray is very 
useful in chronic winter cough or bronchitis, particularly when there is 
present shortness of breath. The pure wine may be used in a spray 
apparatus or be diluted one-half with water. While the throat may 
seem temporarily worse, the shortness of breath rapidly decreases and 
marked improvement takes place in the cough. In order to prevent 
the wine which collects in the mouth from being swallowed, and 
nausea and vomiting thereby induced, the patient should be directed 



IRON. 331 

to rinse his mouth thoroughly every few minutes. The inhalation 
should not last at first over three or four minutes, and, until it is known 
how well the patient will bear the application, the wine should be 
diluted twice or thrice with water and alcohol, equal parts. 

It is stated that powdered ipecac smeared on the skin will greatly 
relieve the pain and swelling produced by the stings of bees. 

Untoward Effects. — The hypodermic use of emetine is prone to 
produce local inflammation and pain. The free use of emetine in 
pregnant or menstruating women is contraindicated owing to its 
stimulating effects on the uterus. In pregnancy not more than J 
grain a day is to be given, as it may cause abortion in larger doses. 
When given in full repeated doses by the mouth, diarrhoea and neuritis 
may develop. This is also true of too generous hypodermic or intra- 
muscular medication, and death from general asthenia and cardiac 
failure may follow its too free use. It seems to have a cumulative 
effect in certain instances. 

Administration. — The syrup (Syrupus Ipecacuanhce, U. S.) is given 
in the dose of J to 1 drachm (2.0-4.0) as an expectorant, or in the same 
dose as an emetic to an infant. Fluidextractum Ipecacuanhce (U. S.), 
Extractum Ipecacuanhce Liquidum (B. P.) should contain 1.5 Gm. of 
alkaloids in each 100 mils, and is given in the dose of 30 minims (2.0) 
as an emetic to an adult. The troches (Trochisci Ipecacuanha', B. P.) 
contain \ grain (0.015) each. Trochisci Morphines et Ipecacuanhce, 
B. P., each of which contains -£$ grain (0.002) of morphine and yV 
grain (0.005) of ipecac, are used in sore throat, dissolved in the mouth. 
Dover's powder (Pubis Ipecacuanha? et Opii, U. S.; Pubis Ipecac- 
uanha Composite?, B. P.) is given in the dose of 5 to 20 grains (0.3- 
1.3). It contains 1 part of opium, 1 part of ipecac, and 8 parts of 
sugar of milk. (See Opium.) The dose of emetine (Emetince hydro- 
chloridum, U. S.), by the needle is ^ to f grain (0.025-0.04). 

The additional British preparations are the pill of ipecac and squill 
(Pilula Ipecacuanhas cum Scilla, B. P.), given in the dose of 5 to 10 
grains (0.30-0.60), and the vinegar of ipecac (Acetum Ipecacuanhce, 
B. P.), given in the dose of 5 to 30 minims (0.3-2.0), which are used 
as expectorants. 

IRON. 

Iron (Ferrum, U. S. and B. P.) is a metal which is used both as a 
medicine and a food — a food because it forms part of the body when 
taken into the organism and is used by the system in the making of 
blood. The number of its official salts and compounds is far in excess 
of the needs of practical physicians, and half the preparations are 
rarely, if ever, used. 

Physiological Action. — Iron has little or no effect upon the system 
when given in a single dose, but repeated doses cause an increase in 
the number of red blood-corpuscles, and plethora, or an increase in the 



332 DRUGS. 

quantity and quality of the blood. Much discussion has arisen as 
to whether iron is absorbed when given as a drug in the form of one of 
the inorganic salts. One theory has been that only the organic iron 
of the food is absorbed, and that metallic iron when given freely allows 
this absorption to go on both by stimulating the bovel and by entering 
into combination with the sulphuretted hydrogen in the intestine, 
thus permitting the organic iron to escape into the system. That both 
forms of iron are absorbed and eliminated is now certain. (For a 
discussion of some of these views, see article on Anaemia.) The ab- 
sorption of iron takes place chiefly in the first twenty inches of the 
small bowel and takes place through the epithelial cells. The iron 
granules are then taken up by the leucocytes and carried to the liver, 
although some of them may be deposited in the mesenteric glands. 
Some of it also is deposited in the bone-marrow. Iron, when it 
enters the stomach, is probably changed into the chloride, and then, on 
entering the duodenum, is changed to the carbonate. If, however, 
iron is given in excessive doses, much of it remains unabsorbed; it is 
changed into the sulphide of iron in the bowels and escapes with the 
feces. Careful studies have shown that the iron, when once absorbed, 
escapes from the body very slowly, and that its pathway of escape is 
not by the bile or in the urine, but by the walls of the colon and rectum, 
which excrete it, so that it may be recovered from the feces. It has been 
asserted that it is never released from the body, but this is untrue. 
Whether it acts as a stimulant to blood-manufacture or simply supplies 
the glands with blood-making material is not known, but the latter is 
probably the correct view. Iron, perhaps, causes oxidation to go on 
more rapidly by reason of its peculiar power of converting oxygen into 
ozone, and in this manner acts as a stimulant to nutrition and bodily 
activity. 

The preparations of iron consist in the soluble and insoluble salts or 
forms. Of these the insoluble are better than the soluble, because 
nearly all the soluble salts of iron are precipitated by the gastric juice 
and have to be slowly redissolved. Nearly all iron preparations are 
capable of acting as more or less powerful astringents, and so are apt 
to cause constipation and to disorder digestion if given in large doses. 
The most astringent of all these preparations are Monsel's salt (the 
Ferri Subsulphas, U. S. and B. P.) and ferrous sulphate (Ferri Sulphas, 
U. S. and B. P.), Closely following these in astringency are the 
ammonio-ferric alum (Ferri et Ammonii Sulphas), and ferric chloride 
(Ferri Chloridum, U. S.). The least astringent preparations are 
Quevenne's iron, or iron by hydrogen (Ferrum Reductum, U. S. and 
B. P.), saccharated ferrous carbonate (Ferri Carbonas Saccliaratus, 
U. S. and B. P.), Basham's mixture (Liquor Ferri et Ammonii Acetatis, 
U. S.), the citrates, tartrates, and the lactate and phosphate of iron. 

Therapeutics. — The chief indications for the administration of iron 
are those forms of anaemia (see Anaemia) characterized by a decrease 
in the normal quantity of haemoglobin in the blood as determined by the 
haemoglobinometer, as, for example, chlorosis. Its chief contraindica- 



IRON. 333 

tion is plethora. When used in small dose (J to J grain — 0.015-0.3) 
it is quite as efficacious as in large amounts, and less apt to disorder the 
stomach, but the doses given in this article are the classical ones usually 
prescribed by physicians. In some cases of anaemia of a semi-pernicious 
type large doses of iron are really needed, probably because the system 
is deranged in such a manner that an excessive loss or elimination of 
iron is constantly present. Large doses compensate for this leakage 
and afford the quantity needed for physiological purposes. Iron should 
not be used as a tonic unless some direct indication for its employment 
is present, and no drug is more abused in this respect than iron. As 
every preparation possesses some peculiarity, the use of each will be 
considered separately. 

Ammonio-ferric Alum. 

Ammonio-ferric alum (Ferri et Ammonii Sulphas), is often given 
in cases of atonic leucorrh&a associated with chlorotic tendencies in the 
dose of 2 to 5 grains (0.12-0.30). It is quite astringent, and should 
not be given in cases of gastric irritability, as it is not suited to such a 
condition. 

Aromatic Mixture of Iron. 

The aromatic mixture of iron (Mistura Ferri Aromatica) contains 
so little iron that it should not be administered in cases where a very 
marked chalybeate influence is desired; it is, however, a useful tonic 
for cases of debility and slight anaemia following long illnesses, given 
in the dose of 1 to 2 fluidounces (30.0-60.0) after meals. Aromatic 
mixture of iron contains cinchona-bark, calumba, cloves, iron, com- 
pound tincture of cardamoms, tincture of orange-peel, and pepper- 
mint-water. 

Arsenate of Iron. 

Ferrous arsenate (Ferri Arsenas) is used in the dose of Tt to tV 
grain (0.004-0.005) in anaemic subjects who are suffering from the 
dry, scaly forms of skin disease which indicate the use of arsenic. 
(See Arsenic.) It is also of value in the anaemia of chronic diarrhoea, 
as both iron and arsenic are useful, not only for the anaemia, but for 
the control of the intestinal disorder. 



Basham's Mixture. 

Under the name of Basham's Mixture (Liquor Ferri et Ammonii 
Acetatis, U. S.) a very useful and elegant preparation of iron is employed. 
It is particularly useful in the anaemia of acute and chronic parenchy- 



334 DRUGS. 

matous nephritis, as it also acts as an efficient diuretic and diaphoretic. 
(See Nephritis.) It is made up as follows: 

Tincture of chloride of iron .... 4 parts. 

Dilute acetic acid 6 " 

Solution of ammonium acetate . . . 50 ' f 

Aromatic elixir 12 " 

Glycerin 12 " 

Water 16 " 

The dose is from 1 to 4 drachms (4.0-16.0), well diluted. 
Bromide of Iron. 

Ferrous bromide (Ferri Bromidum) is said to be useful in ancemia, 
when this state is associated with chorea, in the dose of 5 to 20 grains 
(0.30-1.3), given in syrup. In other nervous diseases accompanied by 
anaemia and insomnia the syrup of ferrous bromide (Syrupus Ferri 
Bromidi) is useful in the dose of J to 1 fluidrachm (2.0-4.0), but its 
sedative properties are not sufficiently marked to render it of much 
value in overcoming restlessness unless it is fortified by one of the 
other bromides. 

Cacodylate of Iron. 

Under the name of cacodylate of iron a compound has been intro- 
duced which is given in cases of ancemia, in which the haemoglobin and 
the corpuscles are lacking, since by this means we obtain the effect of 
both iron and arsenic. The salt may be given by the mouth in the dose 
of \ to 1 grain (0.015-0.06) three times a day, in solution, or in urgent 
cases in the dose of J to J grain (0.008-0.015) by the hypodermic needle 
three times a day. It is asserted by Gilbert and Tereboullet that this 
is not productive of local or renal irritation, and in the albuminuria of 
tuberculosis may even be beneficial. Arsenate of iron is more useful. 

Carbonate of Iron. 

The saccharated ferrous carbonate (Ferri Carbonas Saccharatus, U. S. 
and B. P.) is very slightly astringent, and may be used in pill form 
under the name of Pilules Ferri Carbonatis, U. S. (Pilula Ferri, B. P.), 
sometimes called "Blaud's pill," or in Griffith's pill, which also con- 
tains myrrh. The dose is about 3 grains (0.2), 5 to 15 grains (0.3-1.0), 
B. P. This preparation of iron is largely used for the treatment of 
amenorrhea dependent upon anaemia. Under the name of Mistura 
Ferri Composita, B. P., or Griffith's mixture, a liquid preparation 
is used for the same purposes as the pills just named, in the dose of 
1 to 2 tablespoonfuls (15.0-30.0). Massa Ferri Carbonatis, U. S., 
sometimes called Vallet's mass, is given in pill in the dose of from 
1 to 10 grains (0.06-0.60). 



IRON 335 

Chloride of Iron. 

Tincture of ferric chloride (Tinctura Ferri Chloridi, U. S.; Tinctura 
Ferri Perchloridi, B. P.), often called tincture of the muriate of iron, 
is one of the best and most useful preparations of iron. It is the most 
diuretic preparation of iron. This diuretic effect does not depend 
upon the presence of muriatic ether, as has been taught, since this is 
not present, and is difficult to prepare except there is an excess of chlor- 
ine. According to researches of Dr. S. Weir Mitchell, the only ether 
present is nitrous ether, and this is devoid of power used in small quan- 
tity. As chloride of iron itself is diuretic, it is probable upon this that 
the diuresis produced by it depends. The dose of the ferric chloride 
(Ferri Chloridum, U. S.) is 1 to 3 grains (0.06-0.20). Tincture of 
ferric chloride is considered a specific in erysipelas, and should be given 
in full dose and frequently repeated if it is to be of any service. (See 
Erysipelas.) Ten minims (0.60), well diluted, every hour are not 
too much if the stomach of the patient does not rebel. In chronic 
Bright' 's disease it is of value in that it sometimes decreases the 
albuminuria, but it possesses no curative power for obvious reasons. 
In secondary anosmia it is useful, and owing to its acid content is a 
doubly effective tonic in cases in which not only iron but hydrochloric 
acid is needed. The dose of Liquor Ferri Chloridi, U. S., is 4 to 10 
minims (0.25-0.60). It is rarely used internally, but chiefly as a 
powerful local astringent. Liquor Ferri Chloridi is identical with 
Liquor Ferri Perchloridi, B. P. Tinctura Ferri Perchloridi, B. P., is 
used internally in the dose of 5 to 15 minims (0.3-1.0). 

Given by the stomach, tincture of ferric chloride is useful in tonsillitis. 
It is best to give it in large doses, with an ice-bag placed on the anterior 
part of the neck. When used internally it should be well diluted with 
water and taken through a glass tube to protect the teeth. The 
strong solution of perchloride of iron (Liquor Ferri Perchloridi Fortis, 
B. P.) is a powerful styptic. 

Citrates of Iron. 

The four citrates of iron are soluble in water and so are readily 
added to liquid prescriptions, and they are also of value because they 
are slightly irritant and astringent and do not disorder the alimentary 
canal. Ferri Citras, and Ferri et Ammonii Citras, U. S. and B. P., 
occur in garnet-red scales, and are given in the dose of 5 grains (0.30). 
The solution of the citrate of iron (Liquor Ferri Citratis) is given in 
the dose of 10 minims (0.6). Ammonio-citrate of iron in solution 
in sterile glass ampoules is now placed upon the market for intra- 
muscular use, usually with a small amount of quinine and urea hydro- 
chloride to prevent pain. (See Anaemia.) The Ferri et Quinines 
Citras, B. P., and the Ferri et Strychnin® Citras are given in the dose 
of 3 to 5 grains (0.15-0.3) and 1 to 3 grains (0.06-0.20), respectively. 



336 DRUGS 

Ferri et Quinince Citras Solubilis, U. S., is given in the dose of 3 to 5 
grains (0.15-0.3). 

Dialyzed Iron. 

Dialyzed iron (Ferrum Dialysatum) is a very feeble preparation of 
iron, lacking in astringency, easily precipitated from the solution in 
which it occurs, but at one time largely used in anosmia by some 
practitioners. The dose is 10 to 20 minims (0.30-1.3) in water three 
times a day. Sometimes river-water, if it contains much inorganic or 
organic matter, will precipitate it. Owing to the instability of dialyzed 
iron, it may be used as an antidote to arsenic without further 
preparation. 

Hydroxide of Iron. 

Ferric hydroxide (Ferri Hydroxidum) is the antidote to arsenic, but 
to be efficacious it must be freshly prepared. It is to be made by 
precipitating any liquid preparation of iron by the addition of an 
alkali, such as ammonia, or by the addition of magnesium oxide. 
The resulting precipitate is the antidote, and the supernatant liquid is 
to be poured off. If ammonia is used, the precipitate must be washed 
with water several times to get rid of the alkali, which will render the 
antidote too irritant to be swallowed if it is allowed to remain with the 
precipitate. Magnesia is an antidote in itself, and should be preferred 
under all circumstances. The antidote should be given in excess, and 
as much as a pint of the iron solution should be precipitated. The 
magnesium oxide should be freely added, as too much of it cannot be 
given. The antidote to arsenic is official as Ferri Hydroxidum cum 
Magnesii Oxido, U. S. In the Prussian Pharmacopoeia this is known as 
the Antidotum Arsenici. (See Arsenic, Poisoning by, for official method 
of preparing antidote.) 

Iodide of Iron. 

The syrup of ferrous iodide (Syrupus Ferri Iodidi, U. S. and B. P.) 
is a syrupy liquid of a sweet, iron-like taste, containing about 5 per cent, 
by weight of ferrous iodide. It should contain no free iodine, and if 
a sample of it strikes a blue color with starch it should be discarded. 
It is largely used in anaemia associated with scrofulosis and struma, 
and is useful in the eczema of young children when this is dependent 
upon lack of vitality or anaemia. The dose to a child of two years is 
3 to 6 minims (0.20-0.40), well diluted, and to an adult 30 to 40 minims 
(2.0-2.6) in water* to be taken through a glass tube to protect the 
teeth. 

The saccharated ferrous iodide (Ferri lodidum Saccharatum) is 
used in place of the syrup in the dose of 2 to 5 grains (0.12-0.3). The 
official pills of ferrous iodide (Piluloe Ferri Iodidi, U. S.) each contain 
1 grain (0.06) of ferrous iodide, and are given in the dose of one to 
three pills. 



IRON 337 



Lactate of Iron. 



Ferrous lactate (Ferri Lactas) is soluble in 48 parts of water, and 
is given in the dose of 5 grains (0.30). It is used for the same purposes 
as the other preparations of iron. Ferrous lactate is one of the ingre- 
dients of the formerly official Syrupus Hypophosphitum cum Ferro, 
the dose of which is \ to 1 fluidrachm (2.0-4.0). 

Oxalate of Iron. 

Ferrous oxalate (Ferri Oxalas) is given in the dose of 2 to 3 grains 
(0.12-0.20). It possesses no advantages peculiar to itself. 

Phosphates of Iron. 

There are two phosphates of iron — Ferri Phosphas Solubilis, U. S., 
or Ferri Phosphas Saccharatus, B. P., and Ferri Pyrophosphas Solubilis. 
Ferric phosphate itself is insoluble and is rarely used. The official 
forms are, however, quite soluble, and useful in the dose of 2 to 5 
grains (0.12-0.30). Syrupus Ferri Phosp>hatis, B. P., is given in the 
dose of 1 fluidrachm (4.0). Phosphate of iron is one of the ingredients 
of Syrupus Ferri Phosphatis cum Quinina et Strychnina, B. P., which 
is given in the dose of 1 fluidrachm (4.0), and of the elixir of iron, 
quinine, and strychnine phosphates (Elixir Ferri, Quinince el Strych- 
nines Phosphatum) , given in the same dose as the syrup. 

Reduced Iron. 

Quevenne's iron (Ferrum Reductum, U. S., Ferri Redactum, B. P.) 
is an iron-gray or reddish powder which is frequently adulterated 
with lampblack. If it is pure, it should burn in sparks when dropped 
into a flame; but if. lampblack is present this will not occur. It should 
also yield no sulphuretted hydrogen on adding sulphuric acid to it. It 
is tasteless, and may be given to children for this reason in pills or 
gum-drops, or placed inside of small chocolate creams, or in the form 
of troches (Trochisci Ferri Redacti, B. P.), each lozenge containing 
1 grain (0.06) of the reduced iron. It is used solely in anaemia, and is 
one of the least astringent of the iron preparations. Dose j-$ to 2 
grains (0.006-0.12). 



Subsulphate of Iron, or MonseFs Salt. 

Monsel's solution (Liquor Ferri Subsidphatis, U. S.; Liquor Ferri 
Persulphatis, B. P.) is sometimes wrongly called the solution of the 
persulphate of iron, and is one of the most powerful styptics or haemo- 
statics that we have. It is never to be employed where a hemorrhage 

22 



338 DRUGS 

is to be controlled through the circulation, but only when the solution 
can come in direct contact with the bleeding spot. The objection to its 
use is the hard, black, and dirty clot which it forms on coming in con- 
tact with blood. In hemoptysis Monsel's solution may be used in fine 
spray consisting of from 10 to 60 minims (0.60-4.0) to the ounce (30.0) 
of distilled water. In uterine hemorrhage from any cause the dilution 
may be half-and-half, or if the hemorrhage be from a polypus or the 
cervix uteri the pure solution should be used, locally applied. In nose- 
bleed Monsel's solution may be employed diluted one-half or pure; but 
its use is not to be commended, because of the hard, black clot which is 
formed and the uncomfortable sensations and pain produced in the 
nasal chambers. Plugging the nostrils, and if need be the posterior 
nares, with pledgets of cotton is generally sufficiently efficacious. 

For the intestinal hemorrhage occurring during or after typhoid fever 
Monsel's solution has been given, but ought not to be so employed, as 
it is decomposed in the stomach before it reaches the intestine. In its 
stead Monsel's salt (Ferri Subsulphas) may be given in pills of 3 
grains (0.20) each, the pills being made hard enough to escape into the 
intestine before the stomach dissolves them. One, two, or three pills 
may be given, and repeated in an hour in pressing cases. Hematemesis 
due to bleeding in the stomach may be treated by 3-minim (0.20) 
doses of the solution in a little water. It should be remembered, 
however, that the drug is irritating if frequently repeated. 

In tonsillitis and pharyngitis a quite efficient application is pure 
Monsel's solution applied by means of a pledget of cotton or camel- 
hair brush, or equal parts of the solution and glycerin may be used. 
This application is often as painful as it is efficient, and care must be 
exercised that an excess of the fluid be not present, as it may drop 
into and irritate the larynx. In diphtheria this method of treatment 
may be used if peroxide of hydrogen cannot be obtained. 

The antidote to Monsel's solution is common soap. 

Sulphate of Iron. 

Ferrous sulphate (Ferri Sulphas, U. S. and B. P.) is used internally 
in the dose of 5 grains (0.30) in pill form in chronic diarrhea with 
anemia. Externally, in a solution of the strength of 5 to 25 grains to 
the ounce (0.30-1.6:30.0), it is used as an astringent lotion. Two 
other forms of the sulphate are also employed — namely, the dried 
{Ferri Sulphas Exsiccatus, U. S. and B. P.) and the granulated (Ferri 
Sulphas Granulatus, U. S.), each of which is given in the dose of 3 
grains (0.20). 

Valerate of Iron. 

Ferric valerate (Ferri Valeras) is sometimes used in hysteria with 
anemia, given in the dose of 1 grain (0.06) or more. It possesses a 
very feeble influence as a nervous sedative. 



JALAP 339 

Wines of Iron. 

The bitter wine of iron no longer official is useful as a bitter tonic 
in anosmia in both children and adults, and may be advantageously 
accompanied with cod-liver oil. It is given in the dose of 1 to 2 
fluidrachms (4.0-8.0) or more. This wine is composed of soluble 
citrate of iron and quinine, tincture of sweet orange-peel, syrup, and 
stronger white wine. 

Vinum Ferri Citratis, B. P., is composed of the citrate of iron and 
ammonium, tincture of sweet orange-peel, syrup, and white wine. 
The dose is identical with that of the bitter wine, and it is used for 
the same purposes. 

The plaster of iron (Emplastrum Ferri) is prepared from the hyd rated 
oxide of iron. 

The Liquor Ferri Acetatis, B. P., is given in the dose 5 to 15 minims 
(0.3-1.0). 

Untoward Effects of Iron. — Iron is apt to cause gastric distress and 
frontal headache in persons who are susceptible to its use. Even one 
dose will cause this trouble in some patients. In many instances the 
frontal headache will be found to be due to the constipation which has 
been brought on by the iron, and will be relieved if mild laxatives or 
purges are used. The state of the bowels should always be inquired 
into when iron is being used, and laxatives given whenever constipation 
is present. In rheumatic and gouty persons frontal headaches are a 
common symptom when iron is given, and purgatives will not generally 
give relief. Garrod and Haig have shown that iron decreases the 
elimination of uric acid, and they think this may account for the pro- 
duction of headache in the case of rheumatic patients under its in- 
fluence. Sometimes salts of iron produce vesical irritation and a con- 
stant desire to urinate, causing mucus to form in abnormal amount in the 
bladder. In children its use may result in nocturnal incontinence of urine. 



JALAP. 

Jalap (Jalapa, IT. S. and B. P.) is the tuberous root of Exogonium 
purga (Ipomaa Purga, B. P.), a native of Mexico. It contains two 
resins, jalapin and convolvulin, neither of which is used in medicine 
by itself, though both of them enter into the resin of jalap of the 
U. S. P. The term jalapin is sometimes employed to designate the 
resin. Jalap root should contain not less than 7 per cent, of total 
resin, of which not more than 15 per cent, should be soluble in ether. 

In overdose, jalap or its resin causes vomiting and purging, with 
gastro-enteritis. 

Therapeutics. — Jalap is used in medicine as a hydragogue purge to 
relieve dropsy of any origin. It may be used to deplete in cases of 
general plethora with cerebral congestion, and owing to its tastelessness 



340 



DRUGS 



is a useful active cathartic in children if given in the proper dose — 
namely, 1 to 2 grains (0.06-0.12) in J ounce (16.0) of syrup of rhubarb. 
Combined with calomel, it is preferred to all other purges by some 
practitioners, particularly if the liver is torpid. Jalap in large doses 
must be used with caution in persons who are feeble, and it is contra- 
indicated in cases suffering from gastric or intestinal irritation. 

Administration. — Jalap may be given in the form of the compound 
powder (Pulvis Jalapw Compositus, U. S. and B. P.), dose 15 to 40 
grains (1.0-2.6), which is composed of 35 parts of jalap and 65 parts 
of bitartrate of potassium; and the resin (Resina Jalapce, U. S. and 
B. P.), dose for an adult 2 to 4 grains (0.12-0.25). Owing to the 
small size of the dose of the resin and its lack of taste, this prepara- 
tion is to be preferred for children in the dose of \ to \ grain (0.015- 
0.03). The tincture (Tinctura Jalapw, B. P.) is given in the dose of 
\ to 1 fluidrachm (0.2-4.0) ; the extract (Extractum Jalapce, B. P.) is 
used in the dose of 2 to 8 grains (0.12-0.48). 

JEQUIRITY. 

This is a plant known as Abrus precatorius, the seeds of which are 
poisonous when applied to a wound. An active principle, abrin, is com- 
posed of paraglobulin and a-phytalbumose, which closely resemble 
snake- venom in their action. Jequirity is never used internally in 
medicine in the United States. An infusion of the powdered seeds, made 
by adding J a drachm to an ounce (2.0-32.0) of water at 104° F., may 
be painted with a brush on the inside of the eyelids in cases of chronic 
granular conjunctivitis, in order to produce an acute diphtheritic 
inflammation that will so change the chronic process present as to per- 
mit of cure. If an excessive action is developed, it may be controlled 
by hot compresses made of very dilute solutions of corrosive sublimate. 
The solution of the drug undergoes decomposition with great rapidity, 
and should be freshly prepared each time it is used, or 4 to 8 grains 
(0.25-0.5) of boric acid should be added to preserve it. The drug is a 
powerful cardiac depressant poison when injected into the circulation. 
Whether the seeds produce poisoning when swallowed is doubtful, 
some asserting that they cause gastro-enteritis, others that they are 
harmless. Probably much depends on the activity of digestion and 
absorption at the time of ingestion. 

JUNIPER. 

Juniperus is the fruit or berry of Juniperus communis, an evergreen 
of Northern Europe and America. It contains a volatile oil and an 
amorphous principle, juniperin. 

Physiological Action. — Juniper acts as a gastric stimulant and tonic, 
as a mild diaphoretic if combined with alcohol, and as a marked stim- 
ulating, exciting diuretic. It escapes from the body by the kidneys. 



KAOLIN 341 

Therapeutics. — Juniper is valuable as a stimulant to the genito- 
urinary tract whenever it is depressed or chronically diseased, as in 
chronic pyelitis, nephritis, and chronic catarrh of the bladder. In con- 
gestion of the kidneys, particularly that due to feeble circulation, if not 
accompanied by active renal changes, it relieves these organs and does 
away with albuminuria. Used after an attack of acute Bright's disease 
when reaction has set in and the secreting epithelium of the kidney is 
atonic, it is of value; but care should be taken that all inflammation 
has passed by or it will make the patient worse. In the later stages of 
scarlet fever, in which the renal condition corresponds to that just 
described, juniper is also useful. In old persons a sensation of weight 
across the lumbar region is often quickly removed by the use of juniper 
if the kidneys are inactive. 

Administration. — Juniper is used in the form of the compound 
spirit (Spiritus Juniperi Qompositus, U. S.), composed of the oils of 
juniper, caraway, and fennel, combined with alcohol and water, in the 
dose of 1 to 4 drachms (4.0-16.0). Gin is virtually identical with the 
compound spirit. The infusion of juniper is made by adding an ounce 
(30.0) of the berries to a pint (480 mils) of boiling water and allowing it 
to stand in a warm place for an hour. The entire quantity is to be 
taken in twenty-four hours. This infusion is often combined with an 
ounce (30.0) of acetate of potassium or of the bitartrate of potassium 
in the treatment of dropsy. The spirit (Spiritus Juniperi. U. S. and 
B. P.) is given in the dose of 30 minims to 1 drachm (2.0-4.0). B. P. 
dose 5-20 minims (0.3-1.3). The oil (Oleum Juniperi, U. S. and B. 
P.) is used in the dose of 1 to 4 minims (0.06-0.25). 

KAMALA. 

Kamala, or rottlera, as it is sometimes called, is the glands and 
hairs from the capsules of Mallotus philippinensis , a plant of Abyssinia, 
India, China, and Australia. It contains an active principle, rottlerin, 
which is not official. Given in the dose of 1 to 2 drachms (4.0-8.0), 
kamala acts as a drastic purge and as a remedy for tape-worm, and 
is sometimes used for the removal of ascaris lumbricoides . It should 
be administered in a syrup in which is placed some hyoscyamus to 
prevent griping, and the dose is to be repeated in eight hours if no 
effect is produced. (See Worms.) 



KAOLIN. 

Kaolin (Kaolinum, U. S. and B. P.) is a soft white powder, a 
decomposition-product containing feldspar. It is used externally as 
a dusting-powder in eczema. Cataplasma Kaolini (U. S.) is used as a 
poultice. 



342 DRUGS 

KINO. 

Kino (U. S. and B. P.) is the inspissated juice of Pterocarpus mar- 
supium, a tall tree of India. It contains kinotannic acid, and is used 
as an astringent in the treatment of serous diarrhoea. It is official in 
the form of the tincture (Tinctura Kino, U. S. and B. P.), and is given 
in the dose of 2 fluidrachms (8.0), | to 1 fluidrachm (2.0-4.0), B. P. 
Kino may be used as a gargle in sore throat and for relaxation of the 
uvula. Under the name of compound powder of kino (Pulvis Kino 
Compositus, B. P.) an efficient and pleasant antidiarrhcea powder is 
used. This powder is not official in the U. S. P. The formula for 
each powder is 15 grains (1.0) of powdered kino, 4 (0.2) of powdered 
cinnamon, and 1 (0.06) of powdered opium. 

KOLA. 

This drug is the nut of Kola acuminata, a tree growing in certain 
parts of Africa. The nut depends for its chief medicinal activity upon 
the caffeine which it contains. In addition to this alkaloid it contains 
some theobromine and kolatannic acid, which latter ingredient may 
explain the good results which have followed the use of kola in cases of 
diarrhoea. 

Physiological Action. — The physiological action of kola is, as far as 
we know, nearly identical with that of its near relatives, coffee and tea. 

Therapeutics. — In cases of feeble heart associated with general debility 
kola often proves a valuable stimulant to the heart and general sys- 
tem, as well as to the kidneys. It has also been used vvith asserted 
success in sea-sickness and to sober drunken individuals, although the 
latter power is to be doubted. Its use will sometimes relieve sick and 
neuralgic headache. Recently a large number of semi-proprietary 
articles have been introduced to the laity with the statement that they 
increase muscular strength. Except for their temporary stimulating 
power they are useless for this purpose. The drug is, however, of 
value in cases of uterine inertia during labor in the dose of 30 minims 
to 2 drachms (2.0-8.0) of the fluidextract. 

Administration. — Kola is not official. It may be given in the form 
of the fluidextract (Fluidextr actum Kola:), dose 10 to 30 minims 
(0.60-2.0), or in an elixir. A very useful preparation, known as the 
compound elixir of kola (Elixir Koloe Composita), contains kola, 
coca, and guarana, and may be given in the dose of 2 drachms (8.0). 
This forms a useful tonic in some cases of debility, particularly if 
arsenic is added to it. Thus: 

1$ — Liquoris potassii arsenitis .... TT\,xvj (1.0). 
Elixiris kolae composite . . . . f §iv (120.0). 

S. — Dessertspoonful (8.0) after meals. 



LACTIC ACID BACILLUS 343 

LACTIC ACID BACILLUS. 

Various strains of the lactic acid bacillus have been introduced 
into medicine during the last few years for a number of purposes, of 
which one of the most important is the control of intestinal putrefaction 
of proteids. Claims have been advanced to the effect that a panacea has 
been found for all digestive disorders, and that the universal disease, old 
age, can be postponed by the constant ingestion of these organisms, it 
being thought the changes of old age are caused in large part by the 
absorption into the blood-stream of intestinal toxines. Like many 
other deductions of a sweeping character, this view has a small amount 
of truth as a basis for its existence. As a matter of fact, the internal use 
of lactic acid bacilli is of value in intestinal putrefaction only in those 
cases in which the decomposition of proteids is the chief condition, and 
their employment is of no value, and, indeed, may be worse than useless, 
in cases suffering from fermentation of the carbohydrates ; a state often 
increased by the introduction of the lactic acid bacillus. 

A differentiation of these two conditions can be made in part by 
regulation of the diet and by several methods of examination. When 
proteids are undergoing putrefactive changes the stools are alkaline; 
whereas, the starches, when fermenting, usually produce acid stools. 
Another method of differentiation is by means of Strasburger's fermen- 
tation apparatus. About 5 grammes of feces are placed in the lower re- 
ceptacle of this apparatus and the tube directly above filled with water. 
The whole apparatus is then exposed to a temperature of 100° F. for 
about twenty-four hours, and the amount of gas produced is calculated 
by the quantity of water forced into the third tube. If more than one- 
third of this tube is filled with water and if the feces give a distinctly 
acid reaction, it is fair to assume that the decomposition in the intes- 
tines is due to fermentation of carbohydrates, which contraindicates the 
use of the lactic acid bacillus. 

The second method is to Gram-stain cover-glass preparations counter- 
stained with neutral red. In healthy stools the Gram-negative or- 
ganisms will be present in greatest numbers; the colon bacillus being 
Gram-negative; whereas, in the presence of putrefaction, the blue- 
stained organisms are in excess. In other words, when the blue- 
stained organisms are in excess, the administration of the lactic acid 
bacillus will probably produce advantageous results, and at the same 
time meats must be strictly excluded from the diet. 

The explanation of the good results obtained by this plan of treatment 
lies in the fact that this bacillus produces lactic acid, which exercises a 
deleterious effect upon those organisms which fare badly in the presence 
of an acid medium, as, for example, the bacillus coli, the spirillum of 
cholera, the streptococcus, the bacillus typhosus, and others often found 
in the intestine. 

In addition to their use in the states first named, the bacillus lactis 
has been used in the treatment of those types of infantile diarrhoea in 
which putrefactive changes are present in the bowels, and usually it 



344 DRUGS 

is given to such patients in the form of diluted buttermilk. The bacil- 
lus lactis is also used in cases of rheumatoid arthritis, in which state it 
is believed that septic or bacterial absorption from the bowel is respon- 
sible for the state of the joints. 

In addition to their use internally, these organisms have been used 
locally to combat various septic states, such as slowly healing infected 
surfaces, sinuses, and even in infections due to the gonococcus, particu- 
larly the chronic types in women. One way of employing them is in 
the whey of milk curdled by their action. If the vaginal discharge is 
alkaline the commercial tablets, containing the bacillus in nearly pure 
culture, may be crushed and rubbed up into a powder with sugar of 
milk, which is then dusted over the parts affected after they have been 
thoroughly cleansed by saline solution, but not by antiseptic solutions, 
which will destroy the bacillus lactis. 

The Bulgarian lactic acid bacillus (Bacillus Bulgaricus) seems to 
be the most effective for internal and external use. It is put up in 
compressed tablets; when given by the mouth the dose is 2 or 4 tablets 
after meals, followed by a little sugar to aid its growth (see Butter- 
milk). These may be given powdered and mixed with water to 
infants. It is essential for the preservation of the bacillus that these 
tablets be kept in a refrigerator or other cool container. (See Cholera 
Infantum.) 

LANOLIN. 

Lanolin is the Adeps Lance Hydrosus, U. S. and B. P., a fat con- 
taining not over 30 per cent, of water derived from the wool of the 
common sheep, and is a whitish substance of peculiar stability, very 
difficult of saponification, and incapable of becoming rancid. Unna 
states that ointments of acids, hydrogen peroxide, and other substances 
may be made by it. One great objection to lanolin is its stickiness, 
which is avoided by adding one-third of vaseline. Lanolin is sup- 
posed to possess very remarkable penetrating powers when applied to 
the skin in cases where much infiltration is present, particularly if 
it is combined with resorcin or some similar medicament. In itself 
it has little curative power, and is but little better than lard, suet, 
or any common fat as a basis for ointments. In some rare cases it 
causes irritation of the skin. Adeps Lana?, U. S., is anhydrous wool-fat. 



LEAD. 

Plumbum, or lead, is a metal possessing more or less influence over 
the organism according to the salts which are employed. It is not 
official as lead itself. 

Physiological Action. — Lead, in one of its soluble salts, if applied 
to a mucous membrane, by reason of its astringent effect produces a 
blanching which is particularly noticeable where the blush of inflam- 



LEAD 345 

mation has previously been present. It has little effect when given in 
a single dose, except by an indirect influence over the circulation, 
nervous system, or respiration. (For a description of the effects of 
lead in overdoses see "Poisoning," below.) 

The most irritant and poisonous of the soluble salts is the nitrate, 
the next the subacetate, and the least poisonous of the soluble salts is 
the acetate. 

The insoluble salts rarely cause acute poisoning, but frequently 
produce chronic plumbism. 

Acute Poisoning. — When the acetate of lead is taken in poisonous 
amounts it produces a sweet metallic taste in the mouth, followed by 
pain in the epigastrium and the vomiting of white, milky-looking 
liquids or white curds mixed with food. The white color is due to the 
presence of chloride of lead formed by the acid of the gastric juice. 

The pain rapidly increases in severity, and diarrhoea due to gastro- 
enteritis may be set up, or, in other cases, obstinate constipation is 
present. The passages are generally black, this color being due to the 
presence of the sulphide of lead. At the same time the pulse becomes 
rapid, tense, and cord-like, but after a time weak and compressible. 
The face is anxious and pale or livid. The thirst is excessive and 
cramps in the calves of the legs or muscular twitchings may ensue. It 
is said that the blue line on the gums characteristic of chronic poisoning 
may occur in acute poisoning, but this is rarely, if ever, seen. If coma 
comes on in the course of acute lead-poisoning, death is almost certain. 

The treatment consists in the use of the chemical antidote, a soluble 
sulphate, in large quantity, in the administration of emetics, and the 
use of the stomach-pump if the vomiting produced by the drug is not 
sufficient to rid the stomach of all the poison. The best soluble sul- 
phates to employ are Epsom and Glauber salts, because they are always 
at hand, are readily soluble, and, in excess, act as purges which will 
wash out the intestinal canal. Hot applications should be applied to 
the belly and feet, and the pain and irritation which are present should 
be relieved by opium. 

Chronic Poisoning. — Chronic lead poisoning is rarely produced by 
the soluble salts of lead, nearly always being due to the insoluble salts. 
The symptoms of chronic lead poisoning, or plumbism, are as various 
as it is possible to find variety in the signs of disease of every kind. 
There is no train of symptoms which may not occur, and the occurrence 
of rare, anomalous symptoms in a given case should at once bring to 
the mind of the physician the thought of lead poisoning or syphilis. 
Chronic poisoning occurs in painters, manufacturers of lead salts, and 
every one who is largely brought in contact with the metal in the arts. 
It occurs from the use of hair-dyes containing the acetate of lead, from 
drinking water which has passed through new lead pipe, and even 
from the biting of silk threads weighted with salts of lead. Chromate 
of lead has been used to color sponge-cake when eggs were thought 
too expensive for the purpose, and has killed many persons. Millers 



346 



DRUGS 



who have filled the holes in grindstones with lead have caused wide- 
spread epidemics of what has been called "dry cholera," and many 
persons have suffered from lead poisoning from eating apple-butter 
kept in jars glazed with lead. 

One of the most prominent, but by no means the most constant, 
symptoms of chronic plumbism is bilateral wrist-drop, due to palsy of 
the extensor muscles of the forearm. The short extensor of the thumb 
generally escapes the drug's influence, as does also the supinator 
longus. Foot-drop also occurs, and I am indebted to Dr. H. C. 
Baldwin, of Boston, for the accompanying illustration of this state. 

Fig. 52. 




Drop-wrist and drop-ankle due to chronic lead poisoning. Baldwin's case. 

Sometimes internal squint arises from paralysis of the external rectus 
muscles by the lead. Another very common symptom is severe colic 
centring around the umbilicus and radiating through the belly and 
loins. Obstinate constipation often accompanies these symptoms, and 
the feces, when passed, are white and clay-coloredj owing to a deficient 



LEAD 347 

secretion of bile. During an attack of lead colic the arterial tension is 
increased very markedly, the tongue is coated and whitish, and the 
bowels are obstinately confined. 

If these early warnings are disregarded and the exposure to the lead 
is continued, cerebral symptoms may come on, the result of encephalo- 
pathia saturnina, or saturnine cerebritis. Saturnine epilepsy is not 
very rare. If convulsions come on, death generally ensues. The con- 
vulsions in some cases are not due to a cerebral effect of the lead, but to 
uraemia due to the renal changes which it has caused. 

Renal disease is very commonly produced by lead, and it is not 
uncommon for chronic contracted kidney to be found at the autopsy of 
a sufferer from chronic lead poisoning. If a patient with chronic lead 
poisoning have a urine with a persistent low specific gravity, the prog- 
nosis is grave, as evidencing advanced kidney involvement. 

Asthma due to the inhalation of lead-dust is sometimes met with. 

The most important confirmatory evidence of chronic lead poisoning is 
a blue line on the gums just where they join the teeth. Its absence is not 
a negative sign, however, as poisoned persons cleanly in respect to 
their mouths often do not have it. This blue line is not, however, path- 
ognomonic, as Oliver states that persons who have received large 
doses of bismuth by the mouth, or injected into an empyema, may 
show a similar line. Basophilic degeneration of the red blood cells 
separates the two conditions. Marked cachexia or anaemia is com- 
monly seen in chronic lead poisoning. Not only is basophilic degenera- 
tion of the red blood cells met with in chronic lead poisoning, but 
McJunkin has shown that leucocytes and endothelial cells change 
inorganic lead into a compound soluble in albuminous liquids. 

The blue line may appear early or late. Charter is reports a case in 
which it appeared after taking only four lead and opium pills. In 
another case it did not appear until after 128 grains had been ingested. 

After prolonged lead poisoning the nerve trunks are found atrophied, 
and finally changed, into fibrous cords. iVnterior poliomyelitis may be 
present, but true locomotor ataxia is rarely caused. If ataxic symp- 
toms exist, they are most probably dependent on pseudo-tabes pro- 
duced by a plumbic multiple neuritis, which can be separated from true 
tabes dorsalis by the absence of several of the important true tabetic 
symptoms — such as slow onset, the Argyll-Robertson pupil, etc. — while 
the presence of marked wasting and loss of power, and sometimes 
tenderness over the nerve-trunks, points to neuritis. 

In some cases trophic changes in the joints ensue, and plumbic gout 
is not rarely seen, or even lead arthritis, with deposits of urates in the 
joints. This condition is due to the fact, pointed out by Garrod and 
Haig, that lead forms insoluble salts with uric acid. 

Lead escapes from the body in the urine, the feces, and all secre- 
tions. It is chiefly eliminated by the liver in the bile. 

Treatment of Chronic Poisoning. — The treatment consists in 
three classes of remedial measures: (1) The removal of the cause 



348 DRUGS. 

(2) the removal of the poison in the body; (3) the treatment of the 
lesions produced by the poison. 

In lead colic hepatic purges, such as jalap and calomel, combined 
with opium to prevent pain, are indicated, and alum and opium or 
morphine are said to be almost specifics, the alum in 2-grain doses, the 
others in full amounts. In many cases purges fail to move the bowels 
of a person suffering from chronic lead poisoning, and succeed only 
when morphine is given to overcome the intestinal inhibition produced 
by the irritation caused by the lead. 

To aid in the elimination of the lead, iodide of potassium, which 
forms double soluble salts in the tissues with the metal, is to be used, 
10 to 20 grains (0.6-1.3) three times a day. 

If progressive paralysis is present, Wood insisted on the use of large 
doses of strychnine at the same time that iodide is given. Strychnine 
sulphate should not, of course, be given in the same mixture as the 
iodide, as it is, chemically, incompatible. 

Electricity should be used as a remedy to restore lost function. If 
the faradic current makes the muscles contract, it should be employed, 
and if not, the galvanic current should be used. Curiously enough, 
partial voluntary power sometimes returns before the muscles will 
react at all to electricity. 

It is said that baths of sulphuret of potassium do good in chronic 
plumbism, 5 or 6 ounces (180.0) of the salt to each bath, which is to be 
given in a wooden tub. The patient should afterward be well soaped, 
then thoroughly rinsed off, and rubbed down with a rough towel. 

As the salts of lead are used for different purposes, the therapeutics 
of each one will be taken up separately. 

Acetate of Lead. 

Acetate of lead (Plumbi Acetas, U. S. and B. P.), or sugar of lead, 
has a sweet, astringent taste, and is soluble in water, but the solution 
formed is slightly milky in appearance. 

Therapeutics.— Acetate of lead may be used, and is largely employed 
in the following pill in the treatment of serous diarrhoea: 

~fy— Plumbi acetatis gr. xl (2.60). 

Pulveris opii . . . gr. x (0.60). 

Camphorae gr. xl (2.60).— M. 

Fiant pilulse No. xx. 

S. — One every four hours. 

This pill may also be given in cases of dysentery. 

The acetate of lead in proportion of 1 to 8 grains (0.06-0.5) to the 
ounce of water may be used as an injection for gonorrhoea. 

Lead acetate is also a useful application for the dermatitis produced 
by poison ivy, as this drug precipitates the sticky, non-volatile oil 
of Rhus toxicodendron, recently studied by Pfaff. The acetate 
should be dissolved in alcohol in the proportion of \ grain to the 
ounce (0.03-30.0) and used as a wash. After this the inflamed parts 



LEAD 349 

should be treated by cooling applications, but ointments are not to be 
used, as they dissolve the poisonous oil and spread the irritation. 

The B. P. recognizes the following preparations of lead acetate: 
PilulcB Plumbi cum Opio, dose 3 to 5 grains (0.2-0.3); Suppositoria 
Plumbi Composita, each suppository containing 1 grain (0.06) of opium 
to 3 grains (0.20) of lead acetate; and an ointment (Unguentum Plumbi 
Acetatis). 

Carbonate of Lead. 

Carbonate of lead {Plumbi Carbonas, B. P.), or white lead, is 
insoluble, and is used as a coating or dressing for burns, scalds, or 
ulcers when rubbed up with linseed or other oil, or in the form of the 
ointment (Unguentum Plumbi Carbonatis, B. P.). If an extensive 
surface is covered with this ointment, it may cause subacute lead 
poisoning by absorption. 

Carbonate of lead may be used in the treatment of sunburn in the 
following prescription. 

1$ — Plumbi carbonatis ^j (4.0). 

Pulveris amyli . t s;j (4.0). 

Unguent i aquae rosae 3 j (30.0). 

Olei olivae f 3 i j (8.0).— M. 

S. — Apply to the inflamed skin. 



Iodide of Lead. 

Iodide of lead {Plumbi lodidum) is occasionally employed in 
medicine; the dose is \ to 2 grains (0.03-0.12). Emplastrum Plumbi 
Iodidi, B. P. and Unguentum Plumbi Iodidi, B. P., are used as external 
astringent and alterative applications, but are rarely useful. 

Liquor Plumbi Subacetatis. 

Liquor Plumbi Subacetatis, U. S., and Liquor Plumbi Subacetatis 
Fortis, B. P., or Goulard's extract, is a colorless liquid, much used 
externally, when diluted with laudanum, for sprains, bruises, and 
local inflammations, under the name of "lead-water and laudanum." 
"L. and L.," as it is often called in the hospitals, is a useful applica- 
tion in the dermatitis produced by poison ivy. The proportion should 
be 4 parts of the undiluted lead -water, diluted with 16 parts of water 
to 1 of laudanum, but this is varied as the inflammation or pain is the 
more severe. The official liquor is also official in a dilute solution 
(Liquor Plumbi Subacetatis Dilutus, U. S. and B. P.), and as such is too 
weak for ordinary use, although it is commonly employed. The strong 
solution should be used in the strength of from 1 to 4 ounces (30.0- 
120.0) to the pint (480 mils.) of water. This solution should never 
be employed if the skin is broken, as the drug prevents healing by 
constringing the edges of the wound. 



350 DRUGS 

If some bread-crumbs be saturated with the solution just named and 
applied to an inflamed finger, a felon can often be aborted in its early 
stages. The official dilute solution is useful as a lotion in eczema which 
itches and tingles and is not dry in character. It should be applied 
once or twice a day, and it is well to follow the application of lead with 
a weak sulphur bath or alkaline wash. (See Eczema.) 

Lead-water is also useful in pruritus prudendi. The cerate (Ceratum 
Plumbi Subacetatis, Unguenium Plumbi Subacetatis, B. P.), and the 
glycerin {Glycerinum Plumbi Snbacetatis, B. P.) may be used for 
the same purposes as Goulard's extract. 

Lead acetate is used for the preparation of lead plaster (Emplas- 
trum Plnmbi, U. S. and B. P.), sometimes called "diachylon plaster." 

Hebra recommended for sweating of the feet an application of equal 
parts of lead plaster and linseed oil, applied on linen and wrapped 
around the feet every third day. 

It is interesting to note that in England this plaster has been freely 
applied to produce abortion by the absorption of the lead with resulting 
poisoning. 

Litharge. 

Litharge {Plumbi O.ridum, U. S. and B. P.) is used in the preparation 
of the solution of subacetate of lead. 

LECITHIN. 

Lecithin is found chiefly in those parts of the brain substance which 
contain the largest amount of phosphorus, but it also occurs all through 
the animal body in many cells. The lecithin found on the market is, 
however, derived from the yolk of eggs. It is soluble in alcohol, ether, 
chloroform, and fatty oils, and occurs as a yellowish-white mass. 

Lecithin is used in cases of neurasthenia and in tuberculosis when 
the nervous system is feeble and the patient exceedingly atonic. It has 
also been used as a tonic in all states characterized or accompanied 
by nervous exhaustion, in rickets, and in exophthalmic goitre. In 
neurasthenia and in cases of exophthalmic goitre it not only produces 
marked improvement in the general state of nutrition but also is said 
to act as a nervous sedative. Lecithin is perhaps the most powerful 
substance we have to increase leucocytosis, often doubling or tripling 
the number of the leucocytes. L^nfortunately its taste is very dis- 
agreeable to many patients. It may be given in alcoholic solution or 
pill in the dose of 3 to 5 grains (0.2-0.30) three times a day after meals. 
It is usually wise to have the patient take considerable quantities of 
milk to aid nutrition. If the stomach is out of order, the dyspeptic 
symptoms must be overcome, if possible, before the lecithin is given. 

LEPTANDRA. 

The medicinal portion of Veronica virginica is the rhizome and 
rootlet, from which are made the extract of leptandra (Extractum 



LIPANIN 351 

Leptandrce) and the fluidextract (Fluidextractum Leptandrce). The 
dose of the solid extract is from 1 to 8 grains (0.06-0.5) and of the 
fluidextract 5 to 40 minims (0.30-2.6). 

Physiological Action. — Very few experiments have been made as 
to the action of this remedy, and the only ones of importance are 
those of Rutherford and Vignal, who found that it possesses a moderate 
influence in increasing the flow of bile. In overdose it causes violent 
purging. 

Therapeutics. — Preparations of leptandra, which are not so active 
as is the fresh drug, are excellent substitutes for calomel, according 
to many clinicians. Those who have used leptandra also believe 
it to be of the greatest value in the indigestion of the intestinal type 
sometimes called "duodenal atony." (See also Podophyllin.) The 
following pill is a good method of using the drug in these cases: 

1$ — Extracti chiratce gr. xx (1.3). 

Extracti leptandra? gr. xx (1.3).— M. 

Fiant pilulse No. x. 

S. — One pill after each meal. 

Under the name of leptandrin we have an impure resin which is 
given in the dose of 2 to 5 grains (0.12-0.3). An alkaloid of doubtful 
existence is called leptandrine. 



LEVULOSE. 

Levulose is a monosaccharide sweeter than cane-sugar, and if pure, 
free from glucose. It is used in medicine as a substitute for sugar in 
the dietetic treatment of diabetes and tuberculosis, and is absorbed as 
levulose and is readily oxidized in the body. Levulose may be taken 
by diabetic patients in the dose of 1 to 2 ounces a day without injury 
in many instances, and tends to promote nutrition but in some cases 
it does no better than sugar. It has also been used with advantage 
in poorly nourished children and by tuberculous persons whose diges- 
tion cannot cope with cane-sugar. In po stance sthetic chloroform 
poisoning and in threatened diabetic coma it may be given intra- 
venously or by the Murphy drip. (See Intravenous Injections and 
Enteroclysis, Part III; Diabetes, and Vomiting, Part IV.) When 
given by the vein the dose is about 1 ounce (30.0) to an adult, dis- 
solved in 1 quart (1000) of normal salt solution. When given by the 
rectum it is dissolved in plain water in the strength of \ ounce (15 
Gm.) to 1000 to get good results. 

LIPANIN. 

Lipanin is an artificially prepared mixture devised by von Mering 
as a substitute for cod-liver oil, and consists of 6 parts of oleic acid 
added to 100 parts of olive oil. The advantages possessed by it are 



352 DRUGS 

its lack of disagreeable odor and taste and its ready emulsification 
and digestibility. The commencing dose is 1 drachm (4.0), which 
may be increased to 4 drachms (16.0). This mixture has been found 
of value in most of the wasting diseases in which cod-liver oil is em- 
ployed, and in the opinion of von Mering its efficacy is greatly increased 
if the hypophosphites of lime and sodium are used at the same time in 
the dose of 10 grains (0.60) three times a day. Iodine or one of its 
compounds may also be given simultaneously if it is desired to exert 
an alterative influence. 

LIQUORICE. 

Licorice (Glycyrrhiza, U. S., and Glycyrrhizce Radix, B. P.) is 
the root of Glycyrrhiza glabra, or glandulifera a plant of Southern 
Europe and Asia. The solid extract is used to increase secretion 
in the mouth, and when dissolved in water to form a vehicle for other 
drugs. The powdered solid extract is a very mild and useful laxative. 

Administration. — The solid extract (Extractum Glycyrrhizce, U. S. 
and B. P.) is used in a dose varying from 5 to 120 grains (0.3-8.0). 
The pure extract (Extractum Glycyrrhizce Purum, U. S.) is used in 
the same quantities as the ordinary extract. The fluidextract (Fluid- 
extractum Glycyrrhizce, U. S.) or the liquid extract (Extractum Gly- 
cyrrhizce Liquidum, B. P.) is used in 1- to 2-drachm (4.0-8.0) doses, 
and enters into the preparation of the elixir (Elixir Glycyrrhizce, 
U. S.). Under the name of Brown Mixture, or " Compound Liquorice 
Mixture," a very efficient expectorant solution is official (Mistura 
Glycyrrhizce Gomposita, U. S.), which contains as its most important 
ingredients 120 parts of paregoric, 0.24 Gm. of tartar emetic, and 
30 parts of sweet spirit of nitre, so that half an ounce of the mixture 
contains about ^V grain of tartar emetic. The dose of Brown Mix- 
ture is 1 to 4 drachms (4.0-16.0). Pubis Glycyrrhizce Compositus, 
U. S., and B. P., or compound liquorice powder, contains, according to 
the U. S. P., 18 per cent, of senna, 23.6 per cent, of liquorice, 0.4 per 
cent, of oil of fennel, 8 per cent, of washed sulphur, and 50 per cent, 
of sugar. According to the B. P. it should contain 2 parts of senna, 
2 of liquorice-root, 1 of fennel-fruit, 1 of sublimed sulphur, and of 
sugar 6 parts. The dose is 1 to 4 drachms (4.0-16.0). It is largely 
used as an efficient laxative after childbirth and in cases which suffer 
from constipation chiefly due to the inactivity consequent upon being 
in bed. Finally we have Glycyrrhizinum Ammoniatum, U. S., which 
is the sweet principle of liquorice rendered soluble and easily tasted 
by the addition of ammonia. The dose of this preparation is 5 to 15 
grains (0.3-1.0). 



LITHIUM 353 

LIQUOR POTASSII HYDROXIDI. 

Liquor Potassii Llydroxidi, U. S.; Liquor Potassco, B. P., is a solu- 
tion of potassa containing about 5 per cent, of potassium hydroxide, 
and is a clear, odorless liquid of caustic taste and strongly alkaline 
reaction. It is used in medicine as an antacid and for the purpose 
of decreasing the acidity of the urine. Its dose is 5 to 30 minims 
(0.3-2.0) well diluted with water. 

In cases of ingrowing toe-nail it is often used to soften the nail prior 
to packing with cotton or partial evulsion. 

LITHIUM. 

Lithium is used in several forms, but its salts may be divided into 
two classes — those which act as lithium and those which act as the 
acids forming them. In the first class are the carbonate (Lithii 
Carbonas, U. S. and B. P.), dose 2 to 10 grains (0.12-0.60), 2 to 5 grains 
(0.12-0.3), B. P., the citrate {Lithii CLras, U. S. and B. P.), dose 5 to 
20 grains (0.3-1.3), 5 to 10 grains (0.3-0.6), B. P. In the second class 
are Lithii Bromidum, U. S., dose 10 to 30 grains (0.6-2.0), and Lithii 
Salicylas, dose 10 to 30 grains (0.6-2.0). 

The carbonate and citrate are used in gout and rheumatoid arthritis 
for the purpose of entering into combination with the uric acid in the 
body to form soluble urates and prevent deposits in the joints. They 
have been said to dissolve calculi, but this is untrue, though they 
are used when it is desired to render the urine alkaline. Haig has 
pointed out that although lithium forms salts with uric acid in the test- 
tube, in the body they have a greater affinity for the acid sodium phos- 
phate in the blood, and practically leave the uric acid to itself. This 
is an important point, since it proves that the large amount of water 
generally taken with lithium salts has more to do with relieving gout 
than has the lithia. The carbonate is not soluble in water, and should 
be given in capsule or freshly made pill, but the citrate is soluble. The 
latter may be made from the former by taking 50 grains (3.5) of the 
carbonate, 90 grains (6.0) of crystallized citric acid, and warm dis- 
tilled water 1 fluidounce (30.0). The acid should be dissolved first, 
and the carbonate added to the solution. The solution should then 
be kept hot until effervescence ceases. 

In cases of diabetes depending upon a gouty taint remarkable results 
are said to be obtained from the use of the citrate or carbonate of 
lithium and arsenic. The dose should be ■£$ grain (0.002) of arsenate 
of sodium and 10 grains (0.60) of the lithium salt three times a day. 

It is worthy of note that in some cases citrate of lithium will dis- 
order the stomach ind produce vomiting; and overdoses produce 
general relaxation of the system with a sense of feebleness. 

(For the use of other salts of lithium see the articles on the Bro- 
mides, Salicylic Acid, and Benzoic Acid. See also article on Mineral 
Springs.) 

23 



354 DRUGS 

LOBELIA. 

Lobelia, U. S. and B. P., is the leaves and tops of Lobelia inflata, 
a common weed of the United States. It contains an alkaloid, lobe- 
line, and lobelic acid. 

Physiological Action. — When taken in overdose lobelia causes erne- 
sis, intense prostration, a feeble pulse, pale skin, livid face, muscular 
relaxation, and a cold sweat. Violent purging may be present. It is 
said to paralyze the motor nerve-trunks, and it causes a fall of arterial 
pressure, followed by a rise, the latter change being due to the asphyxia 
which it finally produces. Ultimately it paralyzes the respiratory 
centre and the peripheral vagi. The treatment of the poisoning is 
to administer opium to allay irritation and check vomiting, to give 
alcohol and ammonia to support the heart, and the use of external heat. 

Therapeutics. — Lobelia is used chiefly as an antiasthmatic, and has 
been equally praised and condemned by eminent authorities. The 
reason for this lies in the fact that it is often useless in asthma 
unless given in almost poisonous dose. Wood teaches that it should 
rarely if ever be used, because of its poisonous effects even in doses 
medicinally active, while Sydney Ringer says that the drug is erro- 
neously thought to be dangerous. In asthma both of the gastric and 
bronchial form lobelia is undoubtedly of service. In some cases it 
fails as signally as it succeeds in others. If the asthma is due to or 
associated with cardiac disease, lobelia should never be employed. 
The drug should be taken in the dose of \ drachm (2.0) to 1 drachm 
(4.0) of the tincture at the first sign of an attack, or in 10-minim (0.6) 
doses every fifteen minutes until distinct nausea occurs or relief is 
obtained. If the heart is feeble, its use is contraindicated. 

In atonic constipation with great dryness of the feces 10 minims (0.6) 
of the tincture of lobelia at bedtime are often of service, particularly 
if it is combined with cascara sagarda. (See Cascara Sagrada.) 

Administration. — Lobelia is given in the form of the tincture (Tine- 
tura Lobelia, U. S.), in the dose of 10 to 60 minims (0.60-4.0) as a 
sedative, or 2 to 4 drachms (8.0-16.0) as an emetic. The vinegar 
(Acetum Lobelia) is no longer official, but is given in the dose of 
20 to 30 minims (1.3-2.0), and the fluidextract {Fluidextr actum 
Lobelia, U. S.) in the dose of 1 to 5 minims (0.06-0.30), or as an emetic 
in the dose of 15 minims (1.0). 

In the form of the infusion lobelia is useful as a lotion in the treat- 
ment of the dermatitis produced by poison ivy. The proportion used 
should be an ounce (30.0) to the pint (480 mils.) of water. 

The preparation of the B. P. is Tinctura Lobelia /Ether ea, dose 
5 to 15 minims (0.3-1. 0V 

LYCETOL.v 

(See Piperazine.) 



MAGNESIUM 355 

LYCOPODIUM. 

Lycopodium, U. S., is a pale-yellow powder derived from Lycopodium 
clavatum, a species of moss. It is used by pharmacists as a powder 
in which to roll pills, and by physicians and nurses to prevent the 
intertrigo or chapping of the skin of infants and adults. 

LYSOL. 

Lysol is a preparation made by dissolving in fat and saponifying 
with alcohol that part of tar oil which boils between 190° and 
200° C, and is a brownish, clear, oily fluid, smelling somewhat like 
creosote. It is used for the same antiseptic purposes as creolin (see 
Creolin), but possesses the advantage of forming a clear, soapy fluid when 
mixed with water, in which instruments can be seen. If small instru- 
ments are used, the solution is so soapy that it renders them too slippery, 
for ready use. Those who have used lysol claim that it does not affect 
the skin of the operator's hands except to render it soft and flexible. 
Used upon mucous membranes, a solution of lysol should not be 
stronger than 2 per cent. As a gargle for septic sore throat a 1 per 
cent, solution may be used. Liquor Cresolis Compositus, U. S., is 
similar to lysol. Lysol is much less poisonous than phenol, but a 
considerable number of cases of poisoning by it have been reported. 

MAGNESIUM. 

Magnesium is a metal never used as such, but always in the form 
of one of its salts, which are the sulphate, citrate, carbonate, and sul- 
phite. The sulphite is a natural salt found in sea-water and in caves 
or in the water coming from the latter. The citrate and carbonate 
are derived from the sulphate. The carbonate is insoluble in water 
and alcohol. The others are soluble. 

Magnesium Carbonate. 

The carbonate of magnesium (Magnesii Carbonas, U. S.) is official 
in the form of the heavy and light powder (Magnesii Carbonas Pon- 
derosus and Levis, B. P.), and these two substances do not differ in 
respect to their effects. The light magnesium is never given internally 
because of its bulk, but it is used as a dusting-powder in intertrigo, 
and in the form of white cubes rubbed on the skin to prevent exces- 
sive perspiration and as a cosmetic. The heavy magnesium is used 
as an antacid, and is not, as has been thought by some, in any sense 
a laxative, as it possesses no such power. When the stomach or intes- 
tines contain much acid from fermentative changes, these acids may, 
however, unite with the magnesium and form a slightly laxative salt. 

In sick headaches due to excessive gastric acidity carbonate of magne- 



356 DRUGS 

sium is often of service. The dose of the carbonate is from 5 to 60 
grains (0.30-4.0). It should not be used constantly, as there is danger 
that it will accumulate in the intestines. 

Magnesium carbonate, by increasing the coagulability of the blood, 
may be used in hemophilia, and it is often of value in urticaria. (See 
Calcium Chloride.) 

Liquor Magnesii Bicarbonatis, B. P., is given in the dose of 1 to 2 
ounces (30.0-60.0) as a laxative. 

Magnesium Citrate. 

The citrate of magnesium (Magnesii Citras) is a more irritating 
purge than the sulphate, but it is more agreeable to the taste. It is 
official as Liquor Magnesii Citratis, U. S., which is effervescent and 
should never be used unless freshly prepared. It is made by add- 
ing bicarbonate of potassium to a syrupy solution of the citrate of 
magnesium containing an excess of acid, and corking the bottle tightly, 
the cork being tied down with a strong cord. Care should be taken 
that the bottle is a strong one, as the development of large amounts 
of carbonic acid gas may burst it if it be weak. The dose is half to 
one bottle, which contains about 12 ounces (360 mils.). It is too irri- 
tating to be used when inflammation of the alimentary canal exists, but 
is useful in acute constipation and in sick and bilious headache. 

The effervescent citrate (Magnesii Citras Effervescens) is less 
agreeable to take than the solution just named. It should be dis- 
solved in water, about 1 to 3 drachms (4.0-12.0) of the salt being 
used in each dose, and swallowed while the solution is effervescing. 
It must be kept in bottles tightly corked. 

Magnesium Oxide. 

Magnesia is the oxide of magnesium (Magnesii Oxidum, U. S.), 
made by exposing the carbonate of magnesium to a red heat. It is 
used in the form of the light magnesia (Magnesia Levis, B. P.) as a 
dusting-powder. The troches (Trochisci Magnesia?) each contain 3 
grains (0.20). Magnesii Oxidum Ponderosum, U. S., is official in the 
B. P. as Magnesia Ponderosa. 

Magnesia is an antidote to arsenic, and when employed to precipi- 
tate a soluble preparation of iron it forms the u Antidotum Arsenici" 
(Ferri Hydroxidum cum Magnesii Oxido, U. S.). (See Arsenic.) 

It is important that the student should not confuse magnesia and 
magnesium. The first is the oxide of the second, and is sometimes 
called calcined magnesia. Magnesia and the carbonate of magnesium 
may be used interchangeably. 

"Milk of Magnesia" (Magma magnesia?, U. S.) is a liquid prepara- 
tion of magnesium oxide which is deservedly popular and pleasant. 
It is an aqueous mixture which, by skilful pharmaceutical processes, 
is nearly stable. It is used as a gentle laxative, which is increased in 



MAGNESIUM. 357 

effectiveness if it be followed by a little orange juice, and to correct 
gastric irritability and acidity in both adults and children. It is also 
used as a mouth wash to neutralize acids and to protect the teeth. The 
dose varies from a teaspoonful to a tablespoonful, which may or 
mav not be diluted with water. 



Magnesium Sulphate. 

Sulphate of magnesium (Magnesii Sulphas, U. S. and B. P.) is a 
very soluble white granular powder of neutral reaction and salty taste, 
and is soluble in water. It is generally known as "salts," although 
in some parts of the United States this term also includes the sulphate 
of sodium and " Rochelle salt" or the tartrate of sodium and po- 
tassium. 

'When taken by the mouth in ordinary solutions, it is usually not 
toxic, but if injected into a vein it is very poisonous and kills by respir- 
atory failure. (See Poisoning.) 

Sulphate of magnesium is a purge by reason of its abstraction of 
water from the intestinal bloodvessels, because it stimulates peri- 
stalsis directly and by reason of the fact that solutions of it are not 
readily absorbed. As a result of these three factors free passages 
are produced, the bowel being filled by the water of the original solu- 
tion and the liquid poured out by the bowel wall. All strong saline 
solutions, above the strength of 7 per 1000, abstract liquids from the 
tissues when brought in contact with them, and therefore whenever 
a thorough purgative action is required — that is, where depletion of 
the intestine or absorption of exudations is to be attained — the magne- 
sium should be given in concentrated form, so as to make its solution 
as of high a percentage as possible. 

In cases of dropsy the use of concentrated solutions is particularly 
necessary if free watery evacuations are desired, and from 1 to 2 ounces 
should be given before breakfast or on an empty stomach in as little 
water as will dissolve the salt. (See Dropsy.) Generally it is better 
to give this quantity divided into small doses every fifteen minutes 
till it is all taken. These concentrated solutions are safe if the 
tissues are water logged, but dangerous if they are not. (See 
Poisoning.) 

In enteritis and peritonitis the use of magnesium sulphate has 
largely ceased. It is claimed to be better than ipecac in the treat- 
ment of bacillary dysentery. When used for the latter purpose it 
should be given in drachm (4.0) doses of a saturated solution with 
10 to 15 drops (0.G0-1.0) of aromatic sulphuric acid every two hours. 
The sulphate is not irritating, and may be given freely when inflam- 
mation exists. 

Magnesium sulphate forms a large part of most of the natural 
purgative waters, but in them is present in very dilute form. These 
waters act partly by supplying the contents of the bowel with fluid 



358 DRUGS. 

and thereby softening the feces, the solution not being absorbed 
because of the salt contained in it. 

Sometimes severe attacks of renal pain occur in middle-aged persons 
who have frequent attacks of gravel, and the urine will be found 
to contain octahedral crystals of calcium oxalate. A useful treat- 
ment is to give | to 1 drachm (2.0-4.0) of magnesium sulphate with 
equal parts of citrate of potassium twice or thrice a day, in water, 
for a considerable period of time. 

Magnesium sulphate may be given by enema with the double pur- 
pose of unloading the bowels and acting as a depletant. The best 
mixture for this purpose seems to be that of Watkins — namely, 2 
ounces (60.0) of magnesium sulphate, 1 ounce (30.0) of glycerin, and 
4 ounces (120.0) of water. The B. P. contains an official preparation 
called Magnesii Sulphas Effervescens, which is granulated, and is 
given by the mouth in the dose of 4 to 8 drachms (16.0-32.0). 

Tucker has shown that magnesium sulphate acts as a powerful pain 
reliever and local anesthetic if applied locally in saturated solution by 
means of compresses. For this purpose it may be applied over the 
scrotum in orchitis and over neuralgic nerves. 1 have relieved the pain 
of neuritis in the foot by placing a circular compress wet with mag- 
nesium sulphate about the leg. Used in this manner it is also an 
excellent remedy for erysipelas and to relieve the pain of acute inflam- 
matory rheumatism. In the great war a saturated solution has proved 
an excellent dressing for wounds infected by streptococci, as it inhibits 
their growth. The efficacy of the solution is increased if 10 per cent, of 
glycerin is added to the solution. This also keeps the dressing moist. 

Meltzer and others have shown that the injection of magnesium 
sulphate solution into the subarachnoid space by the intraspinal 
method (see Tropacocaine) aids materially in controlling the spasms 
of tetanus and often causes sleep, although, of course, it does not cure. 
Meltzer uses by intraspinal injection 1 mil. of a 25 per cent, solution 
in water to each 20 pounds of body weight of the patient. The patient 
if in severe convulsions should be chloroformed before the injection, 
and the head should be kept up so that the solution will not find its 
way toward the vital centres. As a rule, the relaxation of the muscles 
lasts about twenty-four hours, after which the injection is to be 
repeated in smaller dose and before the symptoms of the disease 
return in full vigor. This second dose is about 0.8 mil. per 20 pounds. 
Should the injection of the solution result in threatened respiratory 
failure, another puncture should be performed, some of the spinal 
fluid withdrawn and replaced by normal salt solution (see Tropa- 
cocaine for method, Part II), which is no sooner injected than it is 
allowed to escape and fresh saline injected to get rid of or dilute 
the magnesium solution. Meltzer also advises that the 25 per cent, 
magnesium sulphate solution should be given hypodermically three or 
four times a day in the dose of 1 to 2 mils, and even goes so far as to 
advise in very urgent cases the intravenous injection of a 6 per cent. 



MANNA. 359 

solution at the rate of 2 or 3 mils, per minute until the symptoms 
are alleviated or the respiration begins to be depressed. Small amounts 
of calcium chloride solution in the strength of 2.5 per cent, may be 
given intravenously if the magnesium causes respiratory difficulty. 

Poisoning. — Very rarely, when concentrated solutions are given to 
persons who are not dropsical, the drug is absorbed, does not purge, 
and produces systemic poisoning, particularly if the patient has been 
deprived of fluid as in severe diabetes or after excessive vomiting. 
Death may occur, preceded by suppression of urine, toxic convulsions 
followed by paralysis in some cases and not rarely severe vomiting. 
Autopsy reveals patches of redness in the alimentary canal and an 
excess of fluid in the abdominal and other serous cavities. The treat- 
ment consists in the intravenous injection of large amounts of salt 
solution to dilute the magnesium concentration in the tissues and 
blood. The salt solution may be a little less than normal, that is, 0.6 
per cent., instead of 0.9 per cent. When diluted the kidneys can 
eliminate the magnesium, which they fail to do if it is in concentrated 
form. 



MANGANESE. 

Manganum, or manganese, is official in the form of the black 
oxide (Mangani Dioxidum Prcecipitatum, U. S.). Under the name 
binoxide of manganese, it has been highly praised in amenorrhea 
dependent upon functional disturbance and ancemia. The dose 
is 3 to 5 grains (0.20-0.3) three times a day, in pill form, and the 
drug should be taken for a few days before the expected or proper 
date for menstruation. The sulphate is rarely if ever employed, but 
may be tried in malarial jaundice. The dose is 1 to 2 grains (0.06- 
0.12). 

MANNA. 

Manna, U. S., is the concrete saccharine exudation of Fraxinus 
ornus, a tree of Europe. It occurs in roundish masses of varying 
size, looking somewhat like a gray-colored gum arabic. It has a sweet 
taste and odor. Sometimes the taste is a little bitter. 

Therapeutics. — Manna is the most feeble of the laxatives, and 
causes slight flatulence in some persons. In children fed by the 
bottle one of the most frequent disorders in obstinate constipation, and 
for its relief 1 to 2 drachms (4.0-8.0) of the sweet variety of manna 
may be dissolved in the milk of each bottle. When given to older 
children or adults, manna is always combined with other more power- 
ful drugs, chiefly to disguise their taste. It may be combined with 
advantage with rhubarb and senna, and it enters into the official 
Infusum Sennce Compositum, U. S., the dose of which is from 1 to 4 
fluidounces (30.0-120.0). 



360 DRUGS. 



MATRICARIA. 

Matricaria, U. S., German chamomile, consists in the flower-heads 
of Matricaria chamomilla, a European plant, possessing mild bitter 
tonic properties when given in moderate dose. In larger amounts it 
acts as an emetic and anthelmintic. In the form of an infusion of the 
strength of 1 to 2 ounces to the pint (30.0-60.0:480 mils.) it has been 
largely used as a diaphoretic, and, in small doses, to prevent colic in 
teething children. 

MEDINAL. 

(See Barbital Sodium). 

MENTHOL. 

(See Peppermint.) 

MERCUROL. 

Mercurol is a chemical compound of mercury and nuclein, and 
possesses active germicidal power over pyogenic organisms. It is 
said to be particularly destructive to the gonococcus and to be of value 
in both gonorrhoea and gonorrheal ophthalmia. It does not coagulate 
albumin nor act as an irritant, and is readily soluble in water. In 
making the solution it should be placed on the surface of the fluid, as it 
dissolves best in this way. The solution for gonorrhoea should be of 
the strength of J to 1 per cent. In obstinate cases solutions of 2 per 
cent, may be needed. It is best used by injection into the urethra 
in normal salt solution. The internal dose in syphilis is J to J grain 
(0.007-0.013). 

MERCURY. 

Hydrargyrum, U. S. and B. P., mercury or quicksilver, is a heavy 
fluid metal of a peculiar color and appearance. As metallic mercury 
it is used in medicine in the form of the ointments, gray powder, blue 
mass, and the unofficial gray oil, and plaster. 

Physiological Action. — When mercury is taken into the body in one 
of its insoluble and mild preparations it may cause no evidence of its 
presence until by frequent and excessive dosage the system in general 
begins to feel its influence. The first evidences of this are to be found 
in the mouth, and consist in tenderness of the teeth when the jaws are 
firmly and quickly closed, fetid breath, sponginess of the gums, which 
finally may bleed at the slightest touch, swelling of the tongue, and, 
most prominent of all, excessive salivation, a condition sometimes 
called ptyalism. If the use of the drug is persisted in, all these symp- 
toms grow wrose. Eczema, and finally sloughs of the chin and chest 
develop as the result of the constant dribbling of saliva and the direct 



MERCURY. 361 

depressing effect of the drug on the tissues. The teeth drop out, the 
maxillary bones undergo necrosis, and amid a general melting down 
and decomposition of the tissues the patient dies. The blood is 
affected and becomes very thin, fluid, and poor in its corpuscular 
elements. These symptoms ensue on the use of mercury in continued 
overdoses, and rarely follow exposure to the drug in the processes of 
the arts. 

In the making of looking-glasses, barometers, detonators and felt 
hats, workmen are often affected by symptoms varying very widely 
in their course. In some cases the nervous system becomes chiefly 
affected. Tremors of all sorts arise, paralysis agitans is developed, 
and the results of peripheral neuritis ensue; but it is worthy of 
note that the ocular muscles are rarely involved in mercurial tremor, 
while in disseminated sclerosis nystagmus is not rare. Similarly the 
tremors of mercurial poisoning often affect the head and neck alone, 
while in paralysis agitans this is rarely the case. Chorea often comes 
on in chronic mercurial poisoning, and the occurrence of choreic 
movements in an adult should cause inquiry as to any possible exposure 
to mercury. In other cases brownish discoloration of the skin, resem- 
bling Addison's disease, appears. Blindness, deafness, sensory disturb- 
ances, such as hyperesthesia and anaesthesia, may be developed, and 
localized wasting of muscles or groups of muscles may assert itself. 
In still other cases the blood becomes impoverished and mercurial 
cachexia is developed. 

Children under three years are rarely salivated by the use of mercury, 
but this is no reason for using this drug carelessly in this class of cases, 
since the other changes in the organism nevertheless occur. 

Absorption and Elimination. — The rapidity of absorption and 
elimination of mercury depends to a great extent on the variety 
of it which is given. The drug in some forms is so insoluble that 
great delay in its elimination must often ensue because it is slowly 
absorbed. Several opinions are held as to the form in which mercury 
is absorbed. It is usually taught in France that the theory of Miahl 
is correct; this is, that the mercurial preparations are transformed in 
the stomach and intestine into the bichloride, which in turn unites 
with the sodium chloride in the blood and circulates as a double chloride 
of mercury and sodium. In Germany it is taught that it forms an 
albuminate of mercury and so circulates (Henoch's theory), or that 
it forms a chloro-albuminate (Voit's theory). All these theories as 
to its absorption are open to grave criticism. As to the elimination of 
mercury, it is known to escape as an albuminate by every excretion 
of the body — the urine, feces, sweat, tears, milk, and saliva. After 
a single dose the drug begins to be eliminated in about two hours 
according to Byasson, and it is entirely gotten rid of in twenty-four 
hours. If, however, the doses are repeated, it gradually accumulates 
in the body, and is so slowly eliminated as to remain for almost 
indefinite periods of time, and is found deposited in all the organs. 



362 



DRUGS. 



In other words, the doses of mercury ordinarily given are always 
large enough to produce cumulative effects. Thus while Balzer and 
Klumpke agree with Byasson as to the rapidity of elimination of a 
single dose, they find from an experimental study that the amount of 
mercury which can be eliminated by the kidneys for many weeks 
when the body is saturated with the drug is only one-sixteenth of a 
grain a day. It is evident, therefore, that after a full mercurial effect 
is produced it is well to decrease, as do most syphilographers, the 
dose of mercury and give only sufficient to maintain the effect. It is 
also evident that the plan of using iodide of potassium every now and 
again to aid in the elimination of the residual mercury is advisable. 

Contraindications. — Acute or subacute inflammation of the kidneys 
renders the continuous use of mercurial preparations dangerous and 
they should be used cautiously if continued for any length of time 
in all cases of renal disease, as mercury is a renal poison. The state 
of the kidneys should always be carefully investigated before the 
mercury is pushed. 

Therapeutics. — The employment of mercury in medicine centres 
around three great points — viz.: 1st, its value in syphilis; 2d, its use 
as a purge; 3d, its power as an antiseptic and germicide. The first 
function is fulfilled by all the mercury salts more or less perfectly, 
the second only by blue mass and calomel, and the third by the 
bichloride and biniodide of mercury. 

As an AntisyphiliTic. — In syphilis mercury is to be given, not 
because the patient is in this or that stage of the disease, but because 
it destroys the Treponema pallida. Many writers have insisted that it 
ought to be employed only in the secondary stages, and while this is, 
as a general rule, correct, certain conditions may call for it at any time. 

The introduction of salvarsan has in no way displaced mercury as 
an essential part of the treatment of syphilis. The best results are 
obtained by use of both. First the salvarsan, then a course of mer- 
cury. This is well illustrated by the following table prepared by 
Gibbard and Harrison from records in the British War Office which 
shows the great diminution of relapses under mercury and salvarsan 
as compared to the use of mercury alone. There is also a great reduc- 
tion in the number of "sick" days. 





Total 
cases. 


| &.S 

3 2 " 

a £ 
.3-0 

iDos ™ 

g 5> « 

n5 ^ ^ 

< 


Clinical relapses. 


Average time lost by 
each man in days. 


Treatment. 


i? 

o 

<D 
O 

a 

o 


o 

o 

'% 


o 
S 

O 02 

sl 

H 


CD A> 

£ 
"5 <o 

_.H IB 

o ? — 


a 

7" 3 m 

1-13 <3 


"3 
'a 
o 

a 


OS 1 

O 

0> C g 

£ a a 
< 


Total. 


Mercury alone .... 
Mercury and salvarsan 


371 
152 


42.0 
23.2 


151 

6 


115 



49 



315 
6 


83.0 
3.9 


66.2 
25.2 


17.6 
15.8 


83.8 
41.0 



MERCURY 363 

Of all the preparations of mercury used by the mouth in the treat- 
ment of syphilis, the protoiodide is the most popular, and deservedly 
so. (See article on Syphilis.) 

ITIG. 53. 




Lamp for mercurial fumigations. This lamp is made of wire gauze, and resembles the safety- 
lamp of miners, thereby guarding against sudden explosions of the alcoholic vapors. 

Mercury is often administered by means of fumigations or inhala- 
tions both for the removal of local and general syphilitic disorders. 
The best apparatus for either purpose is one devised by Bumstead, and 
it is both simple and inexpensive. It consists of a sheet-iron cup so 
bent that the bottom of the vessel, instead of being flat, projects up- 
ward into the centre of the cup, thereby forming a raised centre with 
a little ditch about it. The top of this projection is flattened, and on 
its apex is placed the calomel which is to be sublimed. The surround- 
ing ditch is then filled with hot water, and the cup placed over an 
alcohol flame, which disengages the vapor of the calomel and water. 
(See Fig. 53.) 

When inhalations are used the face should be held some six or 
eight inches from the cup to permit the fumes to pass through the 
air. Under these circumstances the quantity of calomel used should 
not exceed 4 to 5 grains (0.25-0.30), and the mouth should be rinsed 
out to prevent mercurial stomatitis unless a local action on the buccal 
mucous membrane is desired. Not more than eight or ten inspirations 
should be taken at one sitting. 

If general fumigations are to be practised, the patient places the 
lamp and cup with 30 grains (2.0) of calomel on it under a chair, on 



364 



DRUGS. 



which he sits wrapped in a heavy blanket, and subjects himself not 
only to these fumes, but to a home-made Russian bath, which relaxes 
his skin and aids absorption. (See Fig. 54.) 



Fig. 54. 




A patient prepared for the use of mercurial sublimations. A blanket having been pinned 

tightly around the neck after the patient is stripped, the fumigator shown at his feet is placed 

. under his chair and'the calomel placed on the central disc, as shown in the illustration. Water 

is in the little ditch around it and an alcohol lamp under it. The patient should be given a 

full, warm bath beforehand to cleanse and prepare the skin for absorption. 

The hypodermic use of mercury, if proper antisepsis and care is 
practised, has great advantages. When the symptoms of syphilis are 
urgent this method is to be resorted to and it can be employed when 
salvarsan is contraindicated. (See Arsphenamine.) At such times the 
soluble salts, as the bichloride, are to be employed. (See Mercury 
Bichloride.) When they are not urgent and the patient is not under 
constant observation or cannot be treated regularly the insoluble salts 
are used. These salts are, however, so slowly absorbed that they 
may prove too inactive or finally manifest a cumulative effect. 



MERCURY. 365 

Of the mercurial preparations which may be administered hypo- 
dermically in syphilis, the three which surpass all others are undoubt- 
edly the salicylate of mercury, bichloride of mercury, and gray oil 
(Oleum Cinereum), which was first introduced into medicine by Lang, 
of Vienna. (See Mercury Salicylate, Bichloride of Mercury, and 
Gray Oil, under Mercury.) 

In all cases the injection should be given slowly and deeply into 
some portion of the body in which the tissues are loose, as the buttock 
or the broad of the back, and the skin of the part where the injection 
is to be made should be carefully washed and sterilized by the use of 
green soap and alcohol. 

The intravenous injection of bichloride of mercury has been proved 
so dangerous as to be properly considered unjustifiable. 

It is to be recalled that the herpes seen in advanced syphilitics is 
usually made worse by mercury. Also, that headache due to syphilis, 
if due to a cerebral growth, is benefited by mercury; while that due 
to anaemia and debility complicating syphilis is increased by this drug. 

As A Pukge. — The employment of mercury as a purge or laxative 
having a special action on the liver is constantly resorted to. The two 
preparations used are blue mass and calomel, but the latter is more 
active. They both cause soft or watery stools, according to the dose in 
which they are given, but the blue mass is rarely, if ever, used except 
for the production of a laxative effect. 

Much discussion has arisen as to whether mercury affects the liver, 
and whether the peculiar greenish or brownish-yellow stools produced 
by it are due to the presence of bile or mercury. 

If there is one point firmly fixed in the mind of the average practi- 
tioner of medicine, it is that the mild chloride of mercury increases 
the quantity of bile in the intestine. If such a believer is questioned 
as to whether this increased amount of biliary fluid is due to a true 
increase in secretion or simply to an increase in the flow of bile from 
the gall-bladder, he will either state that he is unable to answer the 
question or that he believes that it is an increased secretion. 

Practically, the position of the profession in general in regard to 
the purgative influence of calomel is that the drug exercises a stim- 
ulating effect upon the biliary gland. Experimentation upon the lower 
animals by several competent observers, and studies made by physio- 
logical chemists, fail, however, to give much light upon this sub- 
ject. It is held by some that calomel never acts as calomel, but 
is converted by the hydrochloric acid of the gastric juice into cor- 
rosive sublimate, and that this drug then stimulates the liver to in- 
creased activity. On the other hand, the best chemical investigations 
show positively that the feeble acidity of the gastric juice and the 
temperature to which the calomel is exposed are not favorable to the 
conversion of a sufficient quantity of calomel into corrosive sublimate 
to account for any hepatic influence, Thus it was found by Ruther- 
ford and Vignal, in their well-known series of studies of the influence 



366 DRUGS. 

of drugs upon the secretion of bile, that if 5 grains (0.3) of calomel 
are subjected, at 100° F., for seventeen hours to the action of normal 
gastric juice, not more than ^ of a grain of mercuric chloride is 
produced. As calomel does not remain in the human stomach for 
more than a day at the utmost, and generally but a few hours, it is 
not likely that as much as ^ of a grain of mercuric chloride is pro- 
duced from the moderately large dose of 5 grains (0.30). In con- 
tradiction of this, Bucheim, Winkler, and others assert that no con- 
version whatever takes place at the temperature of the body, and 
Jaennel's later studies support this view. 

The other theory as to the change which takes place in calomel 
prior to its action upon the liver is that it escapes into the intestines, 
where it is decomposed and the gray oxide of mercury precipitated, 
which may, however, be held in solution by any fatty materials, which, 
being mixed with alkaline liquids, practically form soaps. It is thought 
by Wood and others that this is the more probable result, particularly 
in view of the fact that calomel acts more like blue mass than cor- 
rosive sublimate. Further than this, these opinions are confirmed by 
the fact, with which all of us are familiar, that the hepatic influence 
of calomel is much more positively asserted if at the same time small 
doses of the bicarbonate of sodium are administered. Under these 
circumstances the bicarbonate of sodium naturally diminishes, to some 
extent at least, the acidity of the gastric contents, and also directly 
or indirectly tends to increase the alkalinity of the contents of the 
duodenum. 

As if to increase the complexity of the problem, the studies of 
Rutherford and Vignal seem to prove conclusively that, in the dog 
at least, mercuric chloride has a direct stimulant effect upon the 
hepatic cells; whereas calomel, while producing purgation by increas- 
ing the secretion of the intestinal glands, in no way increases the 
secretion of the bile; and this would seem to indicate that, after all, the 
influence of calomel upon the liver is due to a very minute portion 
of it being changed into corrosive sublimate. Probably the truth of 
the matter is, that we have as yet no definite scientific explanation of 
how calomel really does act. It may be that the solution of the problem 
lies in the hepatic influence exercised by the presence of minute quan- 
tities of corrosive sublimate, and the purgative effect produced by that 
portion of the calomel which has not been converted into the strong 
chloride of mercury. This is rendered the more likely in view of the 
fact that the corrosive sublimate has been found a feeble intestinal 
stimulant, while the calomel has been found to produce active purga- 
tion in dogs, without producing an increase in biliary flow, when the 
drug has been introduced into the duodenum. 

It has been suggested, too, that calomel itself may stimulate the 
bile-expelling mechanism, while the minute portion of corrosive sub- 
limate increases the secretion of the liquid; and, again, that by means 
of the purgative effect that it produces certain substances which have 



MERCURY 367 

been in the intestine are immediately removed, and, as a consequence, 
a depressant influence upon the hepatic cells no longer exists. 

Quite a number of physicians have studied the effect of the various 
so-called cholagogue drugs upon the flow of bile in human beings who 
have had biliary fistula. Perhaps the best studies are those of Pfaff 
and Balch, and more recently those of Joslin, upon women with biliary 
fistula. Calomel and the bichloride of mercury seemed invariably in 
these cases to decrease rather than increase the biliary flow. Ox-gall 
was the only drug which did increase it. 

This subject also is of interest to the practical physician in rela- 
tion to the administration of calomel in compressed tablets or other 
preparations when mixed with what might be called excipients. Under 
these circumstances, if one of the excipients is bicarbonate of sodium 
the tablet after a time almost always undergoes a change and becomes 
of a gray color. Those who have used pills or tablets of calomel which 
have been kept for a long period of time seem to be universally in 
accord with the statement that they have lost the hepatic effect which 
a recently prepared powder always possesses. Thus it has been fre- 
quently found that no biliary flow occurs under the use of stale tablets, 
whereas free bilious purging follows the administration of freshly 
prepared powders. 

Calomel and blue mass are largely used in the condition known as 
biliousness, and undoubtedly give relief. (See Biliousness.) If the 
tongue is heavily coated, the breath foul, the conjunctiva a little 
icteroid, and headache is present, one of them should be employed. 
In remittent malarial fever the use of small repeated doses of calomel 
will often bring relief from the vomiting, and it should always be 
given in the treatment of malarial disease before quinine is used if 
a thorough action of the antiperiodic is to be attained, as it aids in 
the absorption of the drug. 

As a Disinfectant. — The disinfectant and germicidal power of 
bichloride of mercury and of the biniodide is well established by 
clinical experience and experimental investigation. The strength of 
the bichloride solution for antiseptic purposes may vary from 1 to 
2000 to 1 to 20,000 of water, and for disinfectant use from 1 to 500 
to 1 to 1000. (See Antiseptics.) 

In using the bichloride of mercury as an antiseptic it is necessary 
to add a few grains of tartaric acid to the solution to prevent its unit- 
ing with the albumin of the tissues to form an insoluble and useless 
albuminate. The same is true of the use of mercury biniodide. 

As an Antiphlogistic— Formerly it was the belief of a large 
number of physicians that mercury possessed distinct antiphlogistic 
power in the early stages of acute sthenic inflammations, particularly 
if they involved serous membranes. It was the custom to administer 
full doses of calomel guarded with opium when traumatic meningitis 
was feared, and in endocarditis, pericarditis, pleuritis, and peritonitis 
its use was largely resorted to. More recently this plan of treatment 



368 DRUGS. 

has become almost obsolete, not because any deleterious effects have 
followed its use, but apparently as a matter of fashion. The writer 
believes^ that this is a mistake and that in acute inflammations in 
sthenic individuals in the early stages of disease mercury may do good. 

One of the best ways to employ all of the various forms of mer- 
cury is in the form of triturates, which may be prepared by triturating 
10 parts of the drug with 90 parts of milk-sugar. The minute sub- 
division of the medicament aids in its efficiency, because of its more 
ready absorption. 

Leaving the general subject of mercury, we may now consider each 
individual preparation. 

Ammoniated Mercury. 

White precipitate, or ammoniated mercury of the strength of 10 
per cent, with lard (Hydrargyrum Ammoniatum, U. S. and B. P.), is 
used in an ointment (Unguentum Hydrargyri Ammoniati, U. S. and 
B. P.) in various skin affections, when a stimulating application is 
needed, as, for example, in psoriasis and chronic dry eczema. It is also 
sometimes employed as a parasiticide in cases of tinea. The official 
ointment should generally be diluted with lard, as it is far too strong 
and will often induce a dermatitis if used undiluted. 

In ozama, whether syphilitic or not, Trousseau has recommended the 
employment of the following powder as a snuff: 

1$ — Hydrargyri ammoniati gr. iv (0.25). 

Pulveris sacchari albi ...... ^ss(16.0). — M. 

S. — To be used as a snuff, after thoroughly blowing the nose. 

The red precipitate may be used instead of the white. The treat- 
ment removes the stench and may cure the complaint. It may, how- 
ever, irritate the mucous membrane, in which case it should be used 
in the strength of 2 grains to J ounce (0.12-16.0). Ammoniated 
mercury is never used internally. 

Bichloride of Mercury. 

Corrosive mercuric chloride, or corrosive sublimate (Hydrargyri 
Chloridum Corrosivum, U. S.; Hydrargyri Perchloridum, B. P.), is an 
exceedingly poisonous and irritating substance when taken internally 
in concentrated form. 

Taken internally in poisonous dose, it causes violent pain in the 
stomach, vomiting, purging of mucus, blood, and the contents of the 
intestine, collapse, and suppression of urine. The patient should be 
made to swallow large quantities of the antidote, white of egg, the 
stomach should be repeatedly washed out with warm milk by the 
stomach pump, heat should be applied about the body, and the proper 
stimulants be given hypodermically if the pulse or respiration fail. 
If death does not occur within a few hours the gastro-intestinal symp- 
toms often moderate, but the suppression of urinary secretion persists, 



MERCURY. 369 

due to the change produced in the kidneys by the drug. This should 
be prevented, if possible, not only by the free ingestion of water by the 
mouth but also by the rectal drip (see Peritonitis, Part IV), containing 
acetate of potassium or citrate of potassium, 1 drachm to the pint. 
This drip should be persisted in day and night unless anasarca develops, 
when it should be stopped. As a considerable amount of the drug 
is eliminated by the bowel a full colonic lavage should be done twice 
a day to aid in getting rid of the poison. Death may be delayed in 
these cases for many days. Recovery rarely occurs unless the stomach 
is rid of the poison before it can be absorbed in any quantity. 

Not only does the bichloride of mercury produce symptoms of acute 
poisoning when taken in large doses, but it is also capable of causing a 
form of subacute poisoning in those patients who have it applied too 
freely as an antiseptic wash or lotion. Particularly are these symptoms 
developed after intra-uterine or vaginal irrigations with bichloride 
solutions. The symptoms are abdominal pain, diarrhoea with tenes- 
mus, and finally sanguinolent discharges. There is also scanty urina- 
tion or the activity of the kidneys may be entirely suppressed. In 
some cases death comes rapidly, but sometimes even the symptoms 
themselves do not develop for several hours after the drug is employed. 
The bichloride of mercury is an exceedingly useful preparation 
of mercury for hypodermic injection in fulminant syphilis, and is better 
than calomel for this purpose. About J grain (0.01) may be injected 
deeply and gently into the cellular tissues every two or three days. 
^Yhen the injections are made the greatest possible cleanliness should 
be obtained. The syringe barrel should be of glass, the needle and 
syringe should be aseptic, and the hands of the operator well disin- 
fected. The best place for the injection is in the gluteal region or 
between the shoulder-blades. (See Salicylate of Mercury.) 

The intraspinal injection of mercurialized serum has been practised 
with sufficiently good results in cerebrospinal syphilis to justify its 
being mentioned. It would seem that these injections are prone to 
produce more irritation than intraspinal injections of salvarsanized 
serum, and, like such injections, may induce a crisis in ataxia. The 
advantages of the method are that a preliminary intravenous injec- 
tion is not required, and a large amount of serum may be made up 
at one time and kept under strict antisepsis for several weeks. The 
first dose should be small. In ataxia it would appear that the dose 
should be at longer intervals than in other types of cerebrospinal 
syphilis. In the latter the treatments may be as frequent as once or 
twice a week for three weeks. Mercurialized serum is not as effica- 
cious as salvarsanized serum, but may prove a useful substitute, 
although doubt as to the efficiency of intraspinal injections in cere- 
brospinal syphilis seems to be increasing. The following method by 
Haller of preparing mercurialized serum is given. 

In the preparation of mercurialized serum, blood is withdrawn from 
a vein and allowed to clot. The expressed serum is centrifuged in 
24 



370 DRUGS. 

order to free it from cells. The serum is then pipetted into glass 
tubes in 8 mil. amounts, and to each tube is added 0.001 Gm. of mer- 
curic chloride in a 0.1 per cent, aqueous solution. The fluid is agitated 
for a few moments in order to insure a thorough mixing. The white 
ring of precipitated albuminate of mercury quickly redissolves in the 
excess of serum, giving a perfectly clear solution. The tubes are 
plugged and the serum inactivated for thirty minutes at 56° C. They 
are then stored away on ice until needed, when they are warmed to 
body temperature and the serum is administered. 

The amount of serum used has seemed to be of relatively little 
importance, although excessive amounts probably add to the imme- 
diate reaction. From 6 to 8 mils, has been the amount used in most of 
the doses given in spinal syphilis, for the reason that about that amount 
of spinal fluid is usually withdrawn for cell count, globulin and Was- 
sermann tests. The dose of mercuric chloride has been varied from 
0.0005 to 0.002 Gm. The degree of immediate reaction is not per- 
ceptibly changed by increasing the amount to 0.001 Gm., but an 
increase above this figure has seemed to add materially to the dis- 
comfort of the patient. The length of time during which the serum 
was heated to 56° C. has been varied from twenty minutes to two 
hours without apparently affecting the degree of reaction. The age 
of serum does not perceptibly add to its irritating properties. Several 
doses kept on ice for eight weeks and more were followed by less 
disturbance than many which were administered within twenty-four 
hours after preparation. 

Mercury bichloride, aside from its antiseptic use (see Antiseptics), 
is of some value when given internally, not only in syphilis, but to 
aid in combating the pathological lesions induced by that infection, 
as arterioca pillar y fibrosis and chronic contracted kidney. In tonsillitis, 
where the inflammation is severe, it is often used early with great 
service. (See also Mercury Biniodide.) 

In small amounts — that is, in -£$ to -£$ grain (0.001-0.0015) three 
times a day — the bichloride is one of the best remedies for the treat- 
ment of ancemia depending upon a deficient number of blood cells. 
If the anaemia is syphilitic in origin, it is, of course, peculiarly useful. 
Bichloride of mercury is of value in minute doses of -g^o - grain 
(0.0001) for the ill-smelling green stools of summer diarrhoeas in 
adults and children, and it has been recommended that a solution 
be made of \ grain (0.03) in 5 ounces (150.0) of water, and a tea- 
spoonful given every hour until relief is obtained. The water used 
in making the solution should be distilled, and it may be well to add 
to it a little tartaric acid to prevent precipitation of the bichloride by 
organic matter which may have gotten into the water. This treat- 
ment is particularly useful in mucous diarrhoea in which blood and 
mucus are thoroughly mixed. Patients in the dispensaries often speak 
of these passages as containing " corruption," and others think they 
consist of "lumps of flesh," owing to the masses of blood and mucus. 



MERCURY. 371 

Whether the disease be acute or chronic, the bichloride, used in the 
way just described, will be found of service. In dysentery and the 
diarrhoea of adults the same treatment may be resorted to, using 2 
teaspoonfuls of the solution instead oi 1. It is hardly necessary to add 
that the greatest care must be bestowed upon the diet and clothing. 
The author has treated a child suffering from persistent diarrhoea for 
months with varying success, only to succeed when, it being found 
that the abdomen was exposed to the air, the mother was forced to 
apply and keep on the child a flannel binder. 

In some cases in which an obstinate syphiloderm is present J ounce 
(16.0) of corrosive sublimate and 1 ounce (30.0) of chloride of am- 
monium may be added to a warm bath, which should be taken every 
few days. One-half a grain (0.30) of the bichloride of mercury in 6 
ounces (180.0) of water is said to be most efficient as an injection in 
gleet, if used every three or four hours. (See Gonorrhoea.) 

In all parasitic affections of the skin a solution of 2 grains (0.12) 
of bichloride to the ounce (30.0) of water may be sopped on the part 
three times a day. A solution of perchloride of mercury (Liquor 
Hydrargyri Perchloridi) 1 to 1000 is official in the B. P. It is given 
in the dose of \ to 1 fluidrachm (2.0-4.0). 

Tablets for surgical use are now official under the name of Toxi- 
tabellce Hydrargyri Chloridi Corrosivi, U. S. 

(For the antiseptic uses of the bichloride of mercury see Antiseptics 
and Disinfectants.) 

Biniodide of Mercury. 

Red mercuric iodide {Hydrargyri lodidum Rubrum, U. S. and B. P.) 
is a bright red powder, possessing irritant powers equal to or greater 
than those of the bichloride, and causing symptoms, when taken in over- 
dose, closely resembling those produced by the latter drug. Owing 
to the formation of the salt, it is thought to be particularly useful 
in the later stages of syphilis. The dose is -£$ to y 1 ^ grain (0.002- 
0.004). It may also be given intramuscularly dissolved in water or 
oil with ansesthone to prevent pain. The best way to employ it is in 
ampoules. If the oil is used absorption is slower than if water solu- 
tions are employed. The dose so used is \ grain (0.01). (See Syph- 
ilis.) An ointment ( Unguentum Hydrargyri Iodidi Rubri, B. P.) 
is useful as an application in goitre and obstinate skin diseases. In 
the dose of g-J-g- grain every hour for 4 or 6 doses this drug is a most 
useful remedy to abort acute tonsillitis. 

At one time it was thought that biniodide of mercury was a better 
antiseptic than the bichloride, but recent researches have proved that 
this is not a fact. 

Black Wash. 

Black wash (Lotto Hydrargyri Nigra, B. P.) is made by adding 
1 drachm of calomel to a pint (4.0:480 mils.) of lime-water. It is used 



372 DRUGS. 

as a stimulant application for washing syphilitic sores and wounds 
in various forms of eczema. 

Blue Mass. 

Blue mass (Massa Hydrargyria U. S. ; Pilula Hydrargyria B. P.) 
is made by rubbing up metallic mercury with liquorice and other 
excipients, and is often called blue pill. Each grain of the mass con- 
tains \ grain (0.02) of mercury, and it may be given in the dose of 
from \ to 20 grains (0.03-1.3) for the same laxative purposes for which 
calomel is used. Blue mass is rarely employed to produce systemic 
effects. 

Calomel. 

Calomel (Hydrargyri Chloridum Mite, U. S.; Hydrargyri Sub- 
chloridum, B. P.), or mild mercurous chloride, is an insoluble salt 
which is, nevertheless, freely absorbed. 

Calomel when used as a laxative purge should be given in the dose 
of J to ^ grain (0.01-0.03) every half-hour or every fifteen minutes until 
1 or 2 grains (0.06-0.12) are taken, as it will often act as efficiently in 
this way as if 10 grains (0.60) are given at one dose, and there is no 
danger of producing ptyalism. The reason that small doses are as 
efficient as large ones lies in the fact that only the calomel which is 
changed into the gray oxide is active, and, as the amount of alkaline 
juice in the intestine is small, only a minor part of a large dose of 
calomel acts, the major portion escaping unchanged. This is the 
reason that bicarbonate of sodium is added to calomel powders, to aid 
the intestinal juice in the reduction of the salt. While this statement 
as to small dose is true of the use of calomel in temperate climates, 
it does not hold good in hot climates, where much larger doses, 
amounting to 10 (0.60) or even 20 grains (1,3) are often given to affect 
the flow of bile, the hepatic gland being made torpid by heat. If 
purgation does not occur after a full dose of calomel, a saline purge 
must be given at the end of the twenty-four hours, and this muse 
always be used if large doses of the mercurial are employed, to avoid 
possible mercurialization. 

Mercury in the form of calomel has been used hypodermically in the 
treatment of syphilis, being held in suspension by a mucilage. Best 
of all, however, is the employment of chloride of sodium in water with 
the calomel, in the proportion of 5 parts each to 50 parts of water. 
It should be injected deeply into the tissues, not immediately under- 
neath the skin, the greatest cleanliness being necessary to avoid 
abscesses. The best place for these injections is in the fold of the 
buttocks, but sloughing, tetanus, and even gangrene have followed its 
employment in this way. (See also Salicylate of Mercury, Bichloride 
of Mercury, and Gray Oil.) 

In dysentery of the acute form calomel and ipecac are valuable 
remedies. (See Dysentery and Ipecac.) The calomel should be given 



MERCURY. 373 

in small doses, repeated every hour or half-hour until a favorable 
change in the number and character of the stools appears. Calomel 
is not to be used if great asthenia complicates the disease. 

In children who seem constantly "under the weather" and never 
quite well, who have flatulence, fetid breath, and ill-smelling, pasty 
stools, calomel often gives great relief in the dose of -^ grain (0.003) 
every half-hour until four doses are taken, this treatment being 
pursued every fourth or fifth morning. 

In slight jaundice due to cold and hepatic congestion £ grain 
(0.01) of calomel every half-hour until 1 grain (0.06) is taken will 
often bring relief. It is contraindicated in obstructive jaundice. 

Calomel is generally prescribed in conjunction with sugar of milk, 
white sugar, or bicarbonate of sodium, which are added to increase 
the bulk and wieldiness of the powder, and, in the case of the first 
ingredient, to increase its activity by finely grinding it. Owing to its 
lack of taste, calomel is often placed on the tongue in children, and for 
this class of patients white sugar is to be used in small quantity as a 
vehicle, as the other vehicles are less agreeable. The most pleasant 
form of administration is by means of triturates. These should 
not be compressed. 

It is important to remember that calomel when used as an anti- 
syphilitic produces salivation much earlier than the other mercurials. 

Sometimes calomel is of value when dusted into the eye in cases 
of phlyctenular conjunctivitis which are strumous. This practice 
must not be resorted to if iodine or iodides are being taken internally, 
as the iodine is eliminated by the tears and forms a compound which 
burns the conjunctiva. 

A very important use of calomel and one which has been brought 
forward recently as new, but which is really many years old, is its 
employment in dropsy as a diuretic, either alone or combined with 
squills or digitalis, or with opium to prevent purging. The dose is 
small, about 1 grain (0.06) thrice a day, and if a diuretic influence 
does not assert itself in forty-eight hours it should not be continued. 
How calomel acts to produce the increased urinary flow under these 
circumstances is not known. Some suppose that it aids the absorption 
of liquid from dropsical tissues, and so increases urinary secretion; 
others think that it stimulates the renal epithelium to greater activity. 
The latter view seems the least probable of the two, but neither 
theory has been proved correct, although experimentation supports 
the view first named. The full urinary effect of the drug is not felt 
till the second or third day of its use, and speedily passes away, par- 
ticularly as purging is often induced very early. Still another use 
of calomel is in typhoid fever, in which disease it has been highly 
recommended in small repeated doses, particularly if constipation is 
present. In the opinion of the author this is disadvantageous as a 
routine measure and entirely uncalled for, although in the very early 
stages of the disease, when the bowels are confined and the tongue 



374 DRUGS. 

coated, a dose of 1 grain (0.06) in fourths with a little bicarbonate 
of sodium is useful. 

Sydney Ringer has called attention to the fact that in constipation 
or in "biliousness" podophyllin does more good than calomel, provided 
that the stools are dark in color, whereas if the same symptoms are 
present, but the stools light and clayey in color, calomel is more efficient. 
The author has proved the correctness of this assertion so frequently 
that he is convinced of its truth. 

Calomel has been recommended in the condition of anorexia and 
depression following acute diseases, and when the tongue is covered 
by a thick yellow coat it is the remedy for the gastro-intestinal torpor 
always present. While purgative doses of calomel certainly are of value, 
the use of freshly prepared nitromuriatic acid is, however, highly prefer- 
able to the mercurial salt in many such instances. Both of these drugs 
should not be given simultaneously, because they are incompatible. 

Calomel is often given in small doses to " settle the stomach/"' 
Sometimes it will act in this way, but in other cases it will seem to 
increase the nausea and bring on vomiting. This is true of both adults 
and children, and it is impossible to tell beforehand which will occur. 
Ringer asserts that in a peculiar form of vomiting occurring in very 
young children, which comes on immediately after the food is swallowed 
the rejection of milk being forcible, and perhaps so sudden that it is 
not even curdled, and which is not accompanied by much straining, 
calomel will often give relief when all other remedies fail. It should 
not be resorted to until some evidences of wasting occur, as this action 
of the stomach in many children only rids that organ of that part of 
the milk which is in excess, and is a purely physiological regurgitation. 
The calomel may be given in the dose of y 1 ^ grain (0.005) every hour, 
or, if preferred, gray powder in the dose of J grain (0.02) every hour 
for three doses, is equally efficient in these cases. 

Calomel in a fine powder will often remove syphilitic condylomata 
if dusted over them for some time, and an ointment made of 1 drachm 
(4.0) of calomel to 1 ounce (30.0) of lard is very useful in pruritus ani. 

It has been proved that an ointment of calomel if used on the penis 
immediately after sexual intercourse acts as an efficient prophylactic 
against syphilis. The strength used is 4 drachms (15.0) to the ounce 
(30.0). 

Calomel is sometimes given by intramuscular injection in place of 
the salicylate of mercury in treating syphilis. It is best used in the 
dose of 1 to 3 grains (0.05-0.15) suspended in goose oil put up in 
sterile ampoules. 

The B. P. contains a pill mass of calomel, called Pilula Hydrargyri 
Subchloridi Composita, which contains antimony, guaiac resin, and 
castor oil. Its dose is 2 to 8 grains (0.12-0.5). 

Calomel ointment {Unguentum Hydrargyri Subchloridi, B. P.) is often 
useful in the treatment of small patches of eczema, or the following 
prescription may be given : 



MERCURY 375 



1$ — Hydrargyri chloridi mitis . . . . . gr. xl (2.60). 

Magnesii carbonatis gr. xl (2.60). 

Unguenti aquae rosae %] (30.0). — M. 

Gray Oil. 

Gray oil {Oleum Cinereum) is prepared as follows: 2 drachma 
(8.0) of lanolin are rubbed up with sufficient chloroform to emulsify it. 
The rubbing process is continued until most of the chloroform is 
evaporated, and while the mixture is still in a fluid state metallic 
mercury, in double the amount of lanolin, 4 drachms (16.0), is added 
and the trituration continued. By this means an ointment of mercury 
is left which equals 2 parts of mercury and 1 of lanolin. This is some- 
times called strong gray ointment. For hypodermic injection 3 
parts of this gray ointment are added to 1 part of olive oil, or it may 
be still further diluted by adding olive oil in the proportion of half- 
and-half. Of this mixture 1 to 2 minims (0.05-0T) may be injected 
every second or third day. 

By some practitioners this preparation is considered much better 
than any other for hypodermic use in syphilis. 

Mercury with Chalk. 

Mercury with chalk (Hydrargyrum cum Creta, U. S. and B. P.), 
or gray powder, is slightly purgative, but is chiefly employed in the 
treatment of infantile syphilis, as it will not freely purge. It is com- 
posed of 38 parts of mercury, 10 parts of honey, and 57 parts of prepared 
chalk. The dose is 1 to 10 grains (0.06-0.60). Children suffering 
from syphilitic marasmus seem fairly to fatten on it. This preparation 
is also of service in the syphilis of adults, and may be employed whenever 
the laxative effect of mercury is not desired. 

In the treatment of infantile diarrhea with watery, colorless stools 
containing undigested food gray powder in small doses is often very 
useful. 

Mercury Ointment. 

The ointment of mercury, mercurial ointment (Unguentum Hydrar- 
gyri, U. S. and B. P.), is made by rubbing up metallic mercury and 
oleate of mercury with suet and lard until the mercury is extinguished, 
or, in other words, until the globules of mercury cannot be seen with a 
magnifying power of ten diameters. Diluted ointment of mercury 
(Unguentum Hydrargyri Dilutum, U. S.), "Blue Ointment," con- 
taining 67 parts of mercurial ointment in 100 of petrolatum is also 
official. The first of these is the preferable preparation of the two. 

An efficient method of using mercury by inunction is to emplyo 
so-called "Mer curettes" which consist of minutely subdivided metal- 



376 DRUGS. 

lie mercury in cocoa-butter compressed into small blocks, each con- 
taining 30 grains (2.0) of mercury. 

The ointment of mercury is used externally in skin affections and 
for the purpose of influencing the general system. In syphilis the 
ointment in small amounts should be thoroughly rubbed into the skin 
in various parts of the body — one evening in the left groin, the next 
evening in the right groin, the following evening in the left axilla, 
and the fourth evening in the right axilla, beginning on the fifth 
evening in the left groin once more. This avoids local irritation of 
the skin by too frequent applications, places the drug on spots where 
it is readily absorbed, and rapidly influences the system of the patient. 
In infantile syphilis this method may be employed, or a flannel binder 
covered with the ointment may be placed about the belly. The clothes 
should not be changed too frequently, as their saturation aids in 
producing the effects. The wearing of an undershirt saturated with 
the ointment is a valuable, though somewhat dirty, method of produc- 
ing mercurialization. 

When the use of mercurial ointment in the usual areas is inadvisable, 
because its presence is shown to others, it may be applied to the sole 
of each foot on alternate days, the patient wearing dark stockings. 

Under the name of Oleate of Mercury (Oleatum Hydrargyri, U. S. 
and B. P.) a very efficient and more agreeable application than the 
ointment is used in its place or still further diluted with lard, when 
it becomes the Unguentum Hydrargyri Oleatis, B. P. It is made from 
the yellow oxide of mercury. (See Oxides of Mercury.) 

For pediculus pubis, or in any case where parasites, such as the 
flea or louse, infest the region of the genitals or any spot covered by 
a hairy growth, mercurial ointment may be used as a remedy, owing 
to its lethal influence over these pests. Care should be taken that it 
does not cause salivation of the patient, and it must not be allowed 
to remain on the parts, but be wiped off in the course of an hour or 
two or less. " We may here say that if it is once understood that all 
insects, including lice, are destroyed quickly by the application of any 
fixed or volatile oil, physicians will see there is no necessity of employ- 
ing remedies of a noxious character to the patient. The fat of mer- 
curial ointment is probably more active than the mercury itself." 
(Leidy.) 

Linimentum Hydrargyri, B. P., and Emplastrum Hydrargyri, B. P., 
are used or the same purposes as is the ointment of mercury. The 
plaster is made with olive oil, resin, and lead plaster instead of ordinary 
suet or lard. 

Nitrate of Mercury. 

The solution of mercuric nitrate (Liquor Hydrargyri Nitratis Acidus, 
B. P.), acid nitrate of mercury, is an exceedingly active, penetrating 
caustic, so rapid in its effects that it seems to eat into the tissues. 
It may be employed for the removal of epitheliomata and large warts, 



MERCURY. 377 

and should be applied by means of a glass rod. This treatment 
may also be resorted to with advantage in lupus until the surface of 
the growth is level with the skin. The surrounding parts should be 
protected by lard or oil. As this treatment is very painful, the spot 
may be first cocainized and afterward covered with flexible collodion. 
Citrine ointment (Unguentum Hydrargyri Nitratis, U. S. and 
B. P.) is used as a stimulating application in cases of chronic skin 
diseases of the scalp and trunk. It is too strong for ordinary use, 
and should be diluted one-half or less with lard according to the stim- 
ulating effect required; the dilute ointment is official in the B. P. as 
Unguentum Hydrargyri Nitratis Dilutum. 

Oxides of Mercury. 

The yellow and the red mercuric oxides (Hydrargyri Oxidum 
Flavum, U. S. and B. P., and Hydrargyri Oxidum Rubrum, U. S. 
and B. P.), red precipitate, are used largely as a dressing for syph- 
ilitic sores when diluted about one-half with chalk or other powder. 
If used pure, they are somewhat caustic. From the yellow oxide is 
made the oleate of mercury (Oleatum Hydrargyri, U. S., Hydrargyrum 
Oleatum, B. P.), which is used for the same purpose as ordinary mer- 
curial ointment. 

In intestinal and gastric indigestion, with foul belching and very 
ill-smelling stools which are due to intestinal fermentation, the yellow 
oxide is sometimes given in the dose of -^ to -£■$■ grain (0.001-0.0012) 
in a triturate. 

Red precipitate ointment (Unguentum Hydrargyri Oxidi Rubri, 
B. P.) and the ointment of the yellow oxide (Unguentum Hydrargyri 
Oxidi Flavi, U. S. and B. P.) are largely used, diluted one-half with 
lard, for chronic scaly skin affections, in obstinate conjunctivitis, and in 
granular lids and styes. (See Styes.) They should always be freshly 
prepared. 

Protiodide of Mercury. 

Yellow mercurous iodide (Hydrargyri lodidum Flavum, U. S.) is 
much more mild than the biniodide, and is given for exactly the same 
purposes. It is often useful in chronic Bright's disease. It is to be 
remembered as the best mercurial preparation for ordinary cases of 
secondary syphilis. (See Syphilis, Part IV.) It should be given in 
ascending doses. The dose is i to i grain (0.01-0.015) three times a 
day. 

Salicylate of Mercury. 

Hydrargyri Salicylas, U. S., is a drug which has come into quite general 
use since the introduction of the hypodermic method of administer^ 
ing mercury in syphilis. It is to be suspended in paraffin oil (liquid 



378 



DRUGS. 



albolene) in the proportion of 1 grain (0.05) of the salicylate of mer- 
cury to 10 minims (0.6) of the oil, and before it is used the bottle 
must be well shaken in order that the insoluble mercury may not 
remain at the bottom. 

Fig. 55. 









:*{ 


* V 


i 


x , < 





Sites for the mercurial injections. (Gottheil.) 



Salicylate of mercury is also placed on the market in sterile am- 
poules, containing 1 grain (0.06) or more. The drug is suspended in 
a fatty base which in some instances must be heated in order to liquefy 
it. The best ampoules to use are those in which goose oil is employed, 
as it remains in fluid form at ordinary temperature and so does not 
need heating. 

Before giving the injection the buttock should be painted with 
tincture of iodine. The needle should be large and long and well oiled 
before it is used. A 20-gauge needle is the best needle to use to 
carry the heavy fluid. If an oily solution is used the mercurial does 
not attack the metal. The buttock having been sterilized, the injec- 
tion should be given while the patient is in the standing position at 
the sites shown in the above diagram. This method has a great advan- 
tage in point of convenience and pain, as compared to the bichloride 
of mercury which often causes soreness and induration. It is of 
great importance that the needle and syringe should be thoroughly 
cleansed after each injection, as the insoluble drug readily clogs the 



METHYL BLUE. 379 

instrument. One grain should be injected deeply into the muscles 
of the gluteal region every fourth day, and this may be increased to 
every second day if no evidences of the systemic action of the drug 
appear, but these injections should not be continued too long, as 
absorption is uncertain as to speed and ptyalism may be induced. 

Yellow Sulphate of Mercury. 

Hydrargyri Subsulphas Flavus has been used under the name of tur- 
peth mineral as an irritant in chronic ophthalmia and also as a prompt 
emetic in croup. It is a quick and certain emetic, and, it is claimed, 
does not produce depression, but the writer would recommend great 
care in its use. The dose for a two-year-old child is 2 to 5 grains 
(0.12-0.30), repeated in fifteen minutes if necessary. 

If as much as 5 grains (0.30) has been given, and emesis does not 
follow, other emetics or the stomach-pump must be used to prevent 
gastro-intestinal irritation. 

Yellow Wash. 

Yellow wash (Lotio Hydrargyri Flava, B. P.) is made by adding 
30 grains (2.0) of corrosive sublimate to a pint (480mils.) of lime-water. 
It is used for the same purposes as the black wash already mentioned, 
but is much more stimulating. 

Incompatibles. — Bichloride of mercury should never be given with 
any other substance except iodide of potassium and chloride of ammo- 
nium, as it is incompatible with almost every other drug. With the 
iodide of potassium it may be used because the precipitate formed is 
at once redissolved and the resulting mixture is highly alterative. 

Calomel should never be given with iodides or bromides, and hydro- 
chloric acid may convert it into the bichloride if the acid is present in 
any amount. It is also incompatible with antipyrine. 

METHANEMINE. 
(See Hexamethylenamine.) 

METHYL BLUE. 

Methyl blue, or methyl violet, is an aniline dye often sold under 
the name of pyoktanin. When used medicinally it must be per- 
fectly pure and deprived of its usual contaminating matter, arsenic, 
which if present causes local irritation of the part to which it is applied. 
Pyoktanin was introduced to professional notice under this name by 
Stilling as an antiseptic, but careful study has proved it to possess but 
feeble power over the growth of germs. In all conditions of the eye 
in which antiseptic lotions are indicated pyoktanin has been stated to 



380 DRUGS. 

be of value, but elsewhere in surgery it is practically useless as an 
antiseptic. Even in the eye it possesses, according to de Schweinitz, 
a limited range of usefulness, being no better than the older anti* 
septics, except in diseases of the lachrymal apparatus. The fact 
that pyoktanin stains everything it touches is a great disadvantage in 
its use. It may be tried in blepharitis, eczema of the eyelids, conjunc- 
tivitis, both simple and phlyctenular, and in the treatment of corneal 
ulcer. When so employed, it should be applied in the strength of 1 to 
1000 of water. 

It should be remembered that any pure aniline dye may be used 
in place of pyoktanin. Thus some physicians have used yellow pyok- 
tanin or auranine. 

Methyl blue and similar aniline substances have been largely em- 
ployed by some physicians in the treatment of malignant neoplasms. 
The solution (1 to 500 of water) should be filtered through hot asbestos 
to render it sterile, and every antiseptic precaution carefully observed 
in giving the injection. The dose is \ to 3 drachms (2.0-12.0) of 
this solution every other day or every third day, and the injection is 
to be given either into the growth itself if it is large, or just at its side, 
in the healthy tissues, if it is small. Too much should not be injected 
into one spot lest it cause a slough. This treatment does not cure 
the disease. It relieves pain and so quiets the patient, and in rare 
cases checks the growth of the tumor. If the growth sloughs, com- 
plete antiseptic dressing is necessary. An antiseptic pyoktanin-gauze 
dressing should always be used while the treatment is under way. 

METHYL CHLORIDE. 

Methyl chloride is a colorless gas, easily liquefied under pressure, 
with an odor resembling that of ether and chloroform, and is used to 
produce local anaesthesia, which it does by absorbing a large amount of 
heat on passing from the liquid to the volatile state as it strikes the skin. 
It is usually kept in a small flask which has its open end covered by 
a metal cap. When this cap is removed the heat of the hand volatilizes 
the drug, which is then forced out of the flask in a fine spray. The 
nozzle should be held ten to twelve inches from the part to be frozen. 
Before the spray is used the skin of the part to be anaesthetized should 
be washed with soap and ether to remove all fatty substances. 

Under these circumstances the skin becomes pale in a few seconds, 
and afterward white and parchment-like in appearance. Local 
anaesthesia is now complete, and minor surgical operations, such 
as opening boils or abscesses, can be performed without pain. The 
spray should not be continued more than two to four minutes, as local 
death of the tissues may result. Advantages of the spray of methyl 
over that of ether are its slight inflammability and rapidity of action. 
Methyl chloride should not be confounded with methylene chloride. 
The first is monochlormethane, the second dichlormethane. 



METHYLENE BLUE. 381 



METHYLENE BLUE. 



Methylene blue (Methylthionince Chloridum, U. S.) is to be dis- 
tinctly separated in the mind of the student from methyl blue, which 
is practically what is known by the trade name of "pyoktanin." 
The latter ought not to be used internally. Methylene blue occurs as 
a dark-green, crystalline powder, or in the form of prismatic crystals 
having a bronze-like lustre. It is readily soluble in water and somewhat 
less readily in alcohol, the solutions having a deep blue color. Methy- 
lene blue can be distinguished from methyl blue by this test: With 
sodium hydroxide methyl blue gives a purplish red, while methylene 
blue turns a deep violet. Also when a solution of the former is made 
in a test-tube the meniscus is blue, whereas with methylene blue it is 
greenish. 

Methylene blue has been employed in the treatment of malignant 
grotvths and in malarial fevers with asserted success, although its 
successful use in the first group of cases is decidedly problematical. 
When used in the treatment of sarcoma and cancer, from J to 2 grains 
(0.03-0.12) in watery solution are injected daily or on alternate days 
directly into the growth. The neoplasm, it is said, ceases to grow, 
shrinks, and comes away, leaving a fairly healthy sloughing surface. 

This treatment is so uncertain that it should only be tried in inoper- 
able cases, and in this class of patients its local use often seems to 
relieve the pain and check the fetor. 

In malarial fever of the intermittent type methylene blue seems 
to possess distinct curative powers. It is not so powerful as quinine 
by any means, but has its chief sphere of usefulness in patients who 
cannot take quinine or where quinine has been tried unsuccess- 
fully. This antimalarial influence is due to its destruction of the 
Plasmodium malaria*, but its administration must begin from seven 
to ten hours before the expected intermittent paroxysm and be con- 
tinued after the attacks have ceased and for some little time after 
the physician fails to find the micro-organism in the blood, as relapses 
are common. Particularly good results seem to follow the use of 
methylene blue in children suffering from malaria. Untoward symp- 
toms from its use are not common, but when they do occur consist 
in slight vertigo, nausea, and some strangury, which latter symptom 
can be prevented to a great extent if powdered nutmeg (equal parts) 
is given simultaneously. The urine is always blue from the elimination 
of the drug through the kidneys. 

Recently, Levy has employed methylene blue in the dose of from 
1 to 2 grains (0.06-0.12) four times a day in the treatment of migraine. 
It is to be given in capsule with kola. He states that as much as 15 
grains (1.0) may be given in a day with safety. 

Methylene blue has been highly recommended by Horwitz in the 
treatment of the earlier stages of gonorrhoea, as it shortens the course 
of the disease. He suggests the following formula: 



382 DRUGS. 

Methylene blue ........ 2 grains (0.12). 

Oil of sandalwood . . . ' . . . .3 " (0.2). 

Oleo-resin of copaiba 3 " (0.2). 

Oil of cinnamon 1 minim (0.05). 

To be made in one capsule, three of which are to be taken each day. 

Injected into a muscle in the dose of 1 grain in 10 minims of water, 
methylene blue is used to test the activity of the eliminative function 
of the kidneys. In health it should appear in the urine in fifteen to 
thirty minutes, and persist for thirty-six hours. 

When the kidneys are healthy the same test may be made to deter- 
mine whether an effusion in the pleural cavity or peritoneum is capable 
of being absorbed as a result of purgation. From 1 to 3 grains in 
solution are injected into the fluid in the chest, or abdomen, and 
a purge given. If the blue does not appear in the urine, this fact 
shows that absorption from the pleura or peritoneum has not oc- 
curred, because the lymphatics are blocked by inflammatory exudate. 

The ordinary dose in the treatment of malaria is 2 to 4 grains (0.12-. 
0.25) every four hours to adults, or 1 to 2 grains (0.06-0.12) to children 
of five years, preferably given in capsule. 



METHYLENE CHLORIDE. 

Methylene chloride is made from chloroform or by the action of 
chlorine on marsh-gas, and is a colorless liquid resembling chloroform 
in odor. It is readily decomposed by light, which change may be 
hindered by the addition of a little absolute alcohol. 

Therapeutics. — Methylene chloride is employed as an anaesthetic in 
a manner like chloroform, and was introduced as a substitute for 
that drug, but is of doubtful safety and is little used. It has been 
used as a spray for the production of local anaesthesia. As stated 
under Methyl Chloride, it is not to be confounded with that drug. 

In England, under the name of "methylene chloride* * or "methylene," 
a mixture of ethyl chloride and methylene chloride has been widely 
employed by inhalation as an anaesthetic. This preparation is, of 
course, to be distinguished from true methylene chloride. The amount 
of this mixture used to produce anaesthesia is 1 to 2 drachms (4.0-8.0) 
for minor and 3 to 6 drachms (12.0-24.0) for major operations. 
The term "methylene chloride" has also been applied to a mixture of 
chloroform and methyl chloride. 

MUSK. 

Musk {Moschus, U. S.) is the dried secretion obtained from the 
preputial follicles of Moschus moschiferus, or musk deer of Thibet, 
and is a substance possessing remarkably penetrating powers, so far 
as odor is concerned. Very little of the musk for sale in the shops 
is pure, and most of it is not musk at all. Its price varies greatly, but 



MUSTARD. 383 

if sold for less than twenty-five cents a grain it is probably worthless or 
impure. 

Therapeutics. — For some unknown reason musk acts as a diffusible 
stimulant and supports the system. It is also an antispasmodic and 
nervous sedative. In all low fevers where the strength of the patient 
is fast ebbing and the nervous symptoms are those of the most ad- 
vanced depression, rectal injections of musk in starch-water may 
be employed. The dose should be 5 to 10 grains (0.30-0.60). This 
drug is of value where either nervous excitement or nervous collapse 
is present, but is not to be employed until it is absolutely needed to 
carry the patient past a crisis. If frequently employed, it loses its 
power and the expense is a needless one. 

Musk is one of the best remedies in obstinate hiccough. 

The dose of the tincture (Tinctura Moschi, U. S.) is 40 minims to 
1 drachm (2.0-4.0), and of musk itself 5 to 10 grains (0.30-0.60), 



MUSTARD. 

Mustard is official in the form of Sinapis alba, U. S., or white 
mustard, derived from the seeds of Sinapis alba, and Sinapis nigra, 
U. S., or black mustard, derived from the seeds of Brassica nigra. 
An irritant oil (Oleum Sinapis Volatile, U. S. and B. P.) is formed by 
ferment action when black mustard comes in contact with water. An 
albuminoid ferment, myosin, acts in the presence of H 2 on the glu- 
coside sinigrin, forming the oil and dextrose. 

Therapeutics. — Mustard is often used in the form of mustard flour 
as an emetic when stirred in water in the proportion of 2 table- 
spoonfuls to a glass of water. It is also employed as a counterirritant 
and as a condiment. If given in excessive dose, it will cause violent 
gastritis, and chronic gastritis is often set up by its constant use in 
excess. Its internal use is contraindicated during the existence of 
acute gastritis and all states of gastro-intestinal irritation. 

When used as a counterirritant mustard is applied to relieve the 
pain of colic due to flatulence and acute inflammation of the abdominal 
and thoracic viscera, that due to muscular rheumatism, inflamed joints, 
and neuralgia, and it may be applied at the nape of the neck in cases 
of headache and cerebral congestion. When applied to the skin of an 
ordinary individual, it will produce a severe burn if left on more 
than a few minutes, and it should be mixed with wheat, flour in the 
proportion of half-and-half when used upon tender skins. Children 
generally will not tolerate more than one-fourth mustard. The plaster 
should be made by mixing mustard flour and wheat flour together 
and then moistening the mixed flours with warm water or warm vinegar, 
or a little brandy may be used. 

In the capillary bronchitis of young children and in the early. stages of 
the eruptive fevers, when there is torpor and a poorly developed rash, 



384 DRUGS. 

mustard oil may be used in conjunction with the wet-pack in the fol- 
lowing manner. It is particularly indicated when there is paralysis 
of the peripheral capillaries and mottling of the skin. A piece of flannel 
large enough to surround the child from its neck to its feet is wet with 
a mixture made as follows : To 8 ounces (250 mils.) of water at room 
temperature add the same amount of alcohol. To this alcohol-water 
mixture is added 1 to 2 ounces (30.0-60.0) of a mixture composed of 
1 part of oil of mustard and 49 of pure alcohol. After the flannel wet 
in this manner is wrapped about the child, the patient is wrapped again 
in a dry sheet or light blanket and allowed to rest for ten to twenty 
minutes. When the flannel is taken off, the skin is found ruddy with 
blood and the general state improved. The child is now wrapped in a 
dry flannel or blanket and allowed to sleep. This plan cannot be used 
oftener than once in twenty-four hours, because if resorted to too fre- 
quently it will irritate the skin. 

The scald or burn produced by mustard is peculiar in its slowness 
to heal and in the fact that it is tender and reddened for days. Often 
it produces a permanent stain of the skin. If the burning of the mus- 
tard becomes excessive, it should be treated by applying a piece of 
lint soaked in lime-water and olive oil, half-and-half, or olive oil alone 
may be used. 

The oil of mustard is very irritant, and almost epispastic in its 
effects. It is sometimes given in the treatment of the atonic stomach of 
drunkards in the dose of I to \ minim (0.015-0.03). Emplastrum Sina- 
pis, U. S. and B. P., or mustard-papers, are sometimes called sinapisma, 
and these afford a ready means of applying this counterirritant. 
They are generally very strong, and one or two layers of thin and 
moistened linen should be placed between the skin and the sinapism to 
prevent too great an acton. (See Counterirritant.) The compound 
liniment (Linimentum Sinapis Compositum; Linimentum Sinapis, 
B. P.) is composed of the oil of mustard, castor oil, extract of meze- 
reum, and alcohol. The mezereum is omitted in the British prepara- 
tion, which is twice as strong in mustard oil as that used in the United 
States. 

MYRRH. 

Myrrh, U. S. and B. P., is a gum-resin obtained from Commiphora 
myrrha, a tree of Arabia. It occurs in dark-colored tears, and contains 
an active principle, myrrhin. 

Therapeutics. — Myrrh, in medicinal amount, is a stimulant to the 
circulation and to the uterine and the bronchial mucous membranes. 

In amenorrhea due to functional inactivity or anaemia, "iron and 
myrrh" is a standard remedy. (See Iron.) 

The tincture of myrrh, diluted one-half, is useful in ulcerated sore 
throat as a gargle, and the pure tincture is sometimes applied with a 
small brush or by the end of the finger to spongy or tender gums. 

In leucorrhwa depending upon uterine trouble and in chronic cystitis 



NEOARSPHENAMINE. 385 

myrrh is often of service. Sometimes it enters into expectorant mixtures 
given in the later stages of bronchitis. The dose of the tincture (Tinc- 
tura Myrrhoe, U. S. and B. P.) is 10 to 30 minims (0.6-2.0), I to 1 
fluidrachm (2.0-4.0), B. P. It also enters into the composition of Piluloe 
Aloes et Myrrhoe, B. P., dose two to five pills, and Tinctura Aloes et 
Myrrhoe, the dose of which is 1 to 2 fluidrachms (4.0-8.0). 

NAPHTALENE or NAPHTHALIN. 

Xaphthalenum is a coal-tar derivative occurring in colorless, 
shining, transparent lamina 3 , having a strong, characteristic odor re- 
sembling that of coal-tar, and a burning, aromatic taste. It is slowly vol- 
atilized on exposure to air; and by exposure to light acquires a brownish 
color. It is insoluble in water, but when boiled with it, the water 
acquires a faint odor and taste. It is soluble in 13 parts of alcohol at 25° 
C. (77° F.), and very soluble in boiling alcohol; also very soluble in ether, 
chloroform, carbon disulphide, and fixed or volatile oils. After it 
is taken for some time, or even after the first dose, the patient will state 
that when he belches the gas has the smell and taste of burning rubber. 

The drug possesses distinct antiseptic power, and for this reason 
has been employed in certain gastric and intestinal diseases asso- 
ciated with fermentative changes or dependent upon ulceration and 
organic lesions. In fetid diarrhoea it may be given as a deodorant and 
cure. 

When given to children, as in summer diarrhoea, the dose should 
be J to \ grain (0.01-0.015) every two or four hours, but adults may 
take as much as 5 to 10 grains (0.30-0.60). More than this will dis- 
order the stomach. The drug should be given in powder, with sugar, 
or in capsule. It has not been so widely employed as was expected 
when it first came to the notice of the profession, and certainly often 
fails to do good. 

In cats and rabbits naphthalene when administered continuously for 
a considerable period of time produces cataract. 

NEOARSPHEN AMINE. 1 

(Neo s alv ars an . ) 

Neoarsphenamine differs from the older remedy arsphenamine (which 
see) in the following facts: It is not a combination of dioxidiamido- 
arsenobenzol with hydrochloric acid, but with sodium methanal- 
sulphoxylate. It is very soluble in distilled water, and as it has a 
neutral reaction it does not have to be neutralized by sodium hydrox- 
ide. It is less deleterious to the patient, that is, less toxic, and 
therefore can be safely given intravenously in larger doses, but gramme 
for gramme it is less curative, the relative efficiency being 0.9 neo- 

1 By using the term Neoarsphenamine, the physician gets an American product and 
avoids paying a royalty to a German holder of the word neosalvarsan. 
25 



386 DRUGS. 

arsphenamine to 0.5 arsphenamine. Even with these larger doses 
general experience seems to show that it is not as efficacious as the 
older drug. Locally, it is less irritating. (See Arsphenamine.) 

Salvarsan was called "606," whereas neosalvarsan was called "914," 
as that number represents its position in the series of compounds made 
by Ehrlich. It resembles the older product in the following facts: It 
is readily oxidized, and must be prepared freshly for each injection and 
just before the dose is used. Often it does best in advanced syphilis 
if preceded by a course of mercury. It is capable, when given in full 
doses, of causing chills, fever, and impairment of heart action, and if 
the kidneys are inflamed may cause urinary suppression. In other 
words, the indications and contra-indications to its use are identical 
with "606." 

Administration. — The drug, contained in an ampoule, is dissolved 
in 20 to 30 mils, of freshly distilled warm, not hot, sterile water (sse 
Intravenous Injections for precautions) by gentle shaking and given 
at once. Some clinicians dissolve it in sterile saline solution. Vigorous 
shaking may result in oxidation. The intravenous dose varies from 
0.15 to 1.5 Gm. The water should be warmed before, not after the 
mixture is made. 

The doses usually increase in size. Thus the first dose for an adult 
is 0.9 Gm.; the second, 1.2 Gm.; the third, 1.35 Gm.; and the fourth, 
1.5 Gm. These doses may be given on every third day, or at longer 
intervals of ten days until a negative Wassermann test is secured. 
Seven days is a common interval. Women usually receive from 0.75 
to 1.2 Gm., children from 0.15 to 0.35 Gm., and infants 0.05 Gm. 
The intramuscular dose is usually about 0.9 Gm. dissolved in 30 mils, of 
sterile water. To avoid pain when it is used intramuscularly it is best 
to inject beforehand 2 or 3 mils, of a 1 per cent, novocaine solution. 

An easy method of administration is to remove the butt end and pis- 
ton of a large glass syringe capable of holding 10 mils., and to place the 
neosalvarsan in the barrel of the syringe, to w hich is added 4 to 8 mils, of 
sterile normal salt solution. The piston is replaced in the" upper end 
of the barrel, the butt end screwed on, and by gentle shaking a solution 
is obtained ready for injection. The needle is attached to the syringe 
by means of a 'short piece of sterile rubber tubing. The arm. having 
become congested by a hanging posture and by the use of a bandage or 
tourniquet, is placed in a horizontal position and the needle inserted 
into the bulging vein. A slight withdrawal of the piston draws the 
blood into the lower end of the syringe, proving that the vein has been 
entered, and this having been determined, the injection is slowly per- 
formed. If the skin has been properly sterilized and the injection has 
not been into the wall of the vein no local trouble arises. The patient 
should rest quietly for some hours after the injection, if possible, and 
should not receive the injection immediately after a meal. 

Neoarsphenamine is marketed in doses which are equivalent to the 
dosage of arsphenamine; 



NITRATE OF SILVER. 387 

0.15 Gm. neoarsphenamine marketed as Dose No. I = 0.1 Gm. arsphenamine. 

0.3 " " " " " 11=0.2 " 

0.45 " " " " " ITI = 0.3 " 

0.6 " " " " " IV =0.4 " 

075 " " " " " V=0.5 " 

0.9 " " " " " VI = 0.6 " 

NITRATE OF SILVER. 

Nitrate of silver (Argenti Nitras, U. S. and B. P.) is a heavy crys- 
talline salt of silver readily soluble in its own weight of water. 

It is official as the pure nitrate (Argenti Nitras, U. S. and B. P.) 
and as the sticks or fused rolls (Argenti Nitras Fusus, U. S.), or lunar 
caustic. The latter are never used in medicine internally, only the 
crystals being employed. Applied to the tissues of the body or other 
substances, nitrate of silver causes a brown and finally a black stain, 
which is due to the formation of an oxide of silver. 

Physiological Action. — Nitrate of silver is one of the few astringent 
substances which are applicable to inflamed mucous membranes, as 
it is, with lead, bismuth, and zinc, one of the few drugs of this class 
which is not irritant as well as astringent. Locally applied, it acts in 
pure form, as a powerful caustic, which is, however, very superficial 
in its effect, as the drug coagulates the albumin with which it comes 
in contact and thereby forms a coat which protects the tissues beneath. 

The action of the drug upon the circulation, respiration, and similar 
vital functions is only partly known, and has no relation to its employ- 
ment in medicine. 

Nitrate of silver is eliminated from the system very slowly. 

Poisoning. — Almost immediately after the ingestion of a poisonous 
dose of nitrate of silver violent pain in the belly, with vomiting and 
purging, is felt. At the same time evidences of widespread gastro- 
enteritis develop. The abdominal walls are knotted and hard, and 
perhaps scaphoid. The face is anxious and livid and covered with 
a sweat. When vomiting occurs the ejecta are brown or blackish, 
or they may be white and curdy. The lips are at first white, but 
quickly become brown, then black. In some cases the nervous symp- 
toms are severe, and convulsions with delirium may occur. The 
convulsions are epileptiform. Death ensues either from gastro-enteritis 
or from centric respiratory failure, accompanied by a profuse exudation 
of liquid mucus into the bronchial tubes. 

The treatment consists in the use of common salt, which is the 
chemical antidote, the employment of opium and oils to allay irrita- 
tion, and in the ingestion of large draughts of milk and of soap and 
water for the purpose of diluting the poison and protecting the mucous 
membranes of the oesophagus and stomach from the action of the 
irritant. The bodily heat must be maintained. 

Chronic Poisoning. — This is a form of poisoning very rarely seen. 
The most prominent symptom is the pale slate-blue color of the skin, 
which causes the individual to be livid and death-like in appearance. 



388 DRUGS. 

Argyria, as chronic silver poisoning is called, is caused by the con- 
tinued employment of the drug until it is deposited in the tissues. 
It is then found in every part of the body. The first signs of dis- 
coloration can generally be seen in the darkening of the conjunctiva 
over the sclerotic coat of the eye or in a dark line on the inner part 
of the lips. 

The treatment of argyria is not hopeful so far as the color of the 
skin is concerned, but the discoloration may be slightly modified in 
some cases by the prolonged use of iodide of potassium to aid in the 
elimination cf the silver. 

Therapeutics. — Internally this salt is used as a cure for gastric ulcer, 
and it is certainly the best remedy we possess if combined with extract 
of hyoscyamus or opium and given in pill form. In chronic gastric 
catarrh and gastritis nitrate of silver is very useful when the patient 
is troubled with sour eructations or when vomiting occurs after meals. 
When used in these states, it should be given in \ to \ grain (0.01- 
0.015) doses, half to one hour before each meal, in order that the 
stomach may be exposed to its effects and not be protected by food. 

In intestinal ulceration the drug has been highly recommended by 
Pepper, and under these circumstances should be given in hard or 
keratin-coated pills, in order that it may pass through the stomach 
without being chemically changed. In ulceration of the cwcum and 
rectum and in acute and chronic dysentery the disease may be attacked 
by rectal or colonic injections of nitrate of silver. If the caecum is 
involved, the solution must be given in large quantity in order to reach 
the part affected; but if the rectum is diseased, the amount of liquid 
injected should not exceed 4 ounces, the bowel in either case being 
washed out beforehand by warm water to rid it of feces. Soap and 
water and salt and water must not be used for this purpose, as the 
soap or salt which remains in the bowel will prevent the silver salt 
from acting. The strength of the solution employed should be 1 
drachm to 3 pints (4.0-1440 mils.) of water in caecal trouble, and 3 
grains (0.20) to each 4 ounces (120.0) in rectal trouble. If the latter 
condition is very obstinate and chronic, the strength may be increased 
to 5 grains (0.3) to each 4 ounces (120.0). 

Whenever nitrate-of-silver injections are used in this way, a solu- 
tion of salt and water should be ready for use, and injected if the 
action is too severe or as soon as it is thought that the drug has acted 
with sufficient thoroughness. 

Nitrate of silver was at one time thought to be of value in lateral 
and posterior spinal sclerosis, but rarely does good. 

Nitrate of silver has been largely used in epilepsy and chorea, but 
is now seldom so employed, and does little good in most cases. 

Pepper thought highly of the continual administration of nitrate ot 
silver in pill form in the dose of J to \ grain (0.01-0.015) through the 
entire course of typhoid fever, and believed that it greatly modified 
the severity of the disease. 



KIT RATE OF SILVER. 389 

Externally, nitrate of silver is used for many purposes, and will 
often prevent the pitting of smallpox if on the fourth or fifth day the 
vesicles are punctured by a needle dipped in a solution of nitrate of 
silver in the strength of 20 grains (1.3) to the ounce (30.0) of water. 
Others simply paint the skin over the eruption with a solution of 
5 to 10 grains "(0.30-0.60) to the ounce (30.0), claiming that this method 
is equally effective and prevents inflammation and suppuration. 

Higginbottom has highly recommended the use of nitrate of silver 
upon erysipelatous inflammations, but the practice is not often resorted 
to, and is now supplanted by better measures. (See Erysipelas.) In 
other inflammations of a superficial character nitrate of silver is of 
great value. Painted in strong solution over the scrotum in the early 
stages of orchitis or epididymitis, it will often relieve the pain and 
diminish swelling, and felons may sometimes be aborted by its early 
application in concentrated solution over the surface of the finger. 

In all inflammations of the pharynx, larynx, fauces, and mouth 
solutions of silver nitrate may be used in varying strength. Some- 
times after slight exposure to cold or dampness the posterior wall of 
the pharynx suddenly becomes sore and raw, feeling as if the mucous 
membrane had been scarified. A solution of nitrate of silver will 
relieve this condition, and if it is employed in the strength of 60 grains 
(4.0) to the ounce (30.0) of water, the application will be more effica- 
cious and less painful than if weaker solutions are employed. 

In laryngeal phthisis a spray, from an atomizer, in the strength of \ 
to 2 grains (0.03-0.12) to the ounce (30.0) of water may do good service. 

In whooping-cough Ringer recommends the use of a spray in the 
strength given above for the purpose of relieving the cough in vio- 
lence and frequency and of obtaining a good night's rest. The appli- 
cations should be made when the stomach is empty, as they are apt to 
bring on retching. The tip of the atomizer must be within the mouth 
or the skin of the face will be stained. 

In the subacute stages of gonorrhea an injection of nitrate of silver 
of the strength of h grain (0.03) to 3 ounces (90.0) of water is useful. 
(See Gonorrhoea, Part IV.) 

In uterine ulceration and in leucorrh&a when the cervix is boggy 
and tender, the application of the solid nitrate-of-silver stick is of 
service. Its use is often followed by headache about the vertex, and 
this in turn is to be relieved by 10-grain (0.60) doses of the bromides. 

In pruritus pudendi vel ani and vulva sl solution of 4 to 6 grains 
to the ounce (0.25-0.40 : 30.0) should be painted with a camel-hair 
brush over the parts to relieve the itching. The application is to be 
made from two to four times a day. 

Bed-sores may be aborted if, as soon as the skin reddens, an aqueous 
solution of nitrate of silver of the strength of 20 grains to the ounce 
(1.3-30.0) is applied with a brush to the part. For obvious reasons 
this measure often fails in paralytics. 

Boils which begin in a small limited papule with a surrounding 



390 DRUGS. 

area of inflammation may sometimes be aborted by painting a strong 
solution of this salt around them. 

In granular lids, conjunctivitis, and similar affections about the eye 
nitrate of silver in stick form or in solution is largely and successfully 
employed. As a prophylactic for ophthalmia neonatorum it is invalu- 
able, and in most cases a 1 per cent, solution is adequate. If infec- 
tion is present, 2 per cent, should be used. The. pain caused by the 
use of this salt in the eye can be modified by the addition to the ordinary 
watery solution of 15 per cent, of glycerin, which seems to increase the 
penetrative and antiseptic effect of the drug. (See Conjunctivitis.) 

When it is desired to remove nitrate-of-silver stains, they should 
be washed with a solution made of cyanide of potassium 2\ drachms 
(10.0), iodine 15 grains (1.0), and water 3 ounces (90.0); or dissolve 15 
grains (1.0) of corrosive sublimate in 7 ounces (210.0) of boiled 
water, add about 45 grains (3.0) of table salt (a scant teaspoonful) 
just before using, lay the stained materials in the mixture for about 
five minutes, and then wash them two or three times in pure water. 

Administration. — The dosp of nitrate of silver is \ to \ grain (0.01- 
0.015) in pill form. Miiigated caustic, or mitigated nitrate of silver 
(Argenti Nitras Mitigatus, B. P.), is composed of equal parts of nitrate 
of silver and potassium nitrate, and is good as a mild caustic. 

The drug when given continuously should be discontinued for two 
weeks at the end of the eighth week, as it is so slowly eliminated that 
it accumulates in the body and causes argyria; but Lewin and Soullier 
assert that the smallest aggregate amount on record which has pro- 
duced argyria is 1 ounce. 

NITRIC ACID. 

Nitric acid (Acidum Nitricum, U. S. and B. P.), the strongest and 
most corrosive of the mineral acids used in medicine, is a clear liquid, 
becoming slightly yellow with age. It should be kept in dark, glass- 
stoppered bottles. 

Physiological Action. — When in pure form, nitric acid acts upon 
the tissues of the body as a powerful caustic. Applied to the mucous 
membranes, well diluted, it acts as an irritant or astringent, and when 
taken internally it exerts a stimulating influence over the secretory 
glands of the stomach and small intestine. It does not tend to relax 
the bowels, as does nitro-hydrochloric acid. Continued for a long 
period of time in small doses, it is said to cause slight salivation and 
looseness of the teeth. Nitric acid coagulates albumin. 

Poisoning. — When nitric acid is taken in concentrated form, it pro- 
duces a widespread gastro-enteritis, intense pain in the mouth, oesoph- 
agus, and abdomen, and finally death from the inflammation induced 
or from collapse. If the patient survives the acute stages, he may 
die from secondary changes in the stomach and bowels, such as stric- 
ture or destruction of the peptic tubules. The stain made by the 
acid about the mouth and on clothing is deep lemon-yellow. Renal 



& 



NITRIC ACID. 391 

irritation is often a severe symptom, and the urine and the passages 
from the bowels may be bloody. 

The antidotes are any mild alkali, as magnesia, chalk, or plaster 
from the walls of the room, the use of oils and opium to relieve irrita- 
tion, and the maintenance of bodily heat. 

Therapeutics. — Nitric acid is used externally in medicine as a caustic 
for chancres and chancroids, the surrounding tissues being protected 
by oils or ointments. 

Nitric acid may also be used on warts, in cases of gangrene to destroy 
the tissues, and on phageden ic ulcers. Whenever the acid is to be applied 
for such purposes, a solution of soap and water should be at hand to 
neutralize the effects as soon as it has acted deeply enough. Nitric 
acid is also used externally in a dilute form, 5 to 30 minims to the 
ounce (0.30-2.0: 30.0) of water, as a stimulant and astringent to indo- 
lent ulcers. 

Internally, nitric acid is used as a tonic and astringent. In the 
oxalic-acid diathesis when oxaluria is present, nitric acid will give 
relief when nitromuriatic acid cannot be obtained, although the latter 
is preferable. When small ulcers exist in the mouth or stomatitis is 
present, 3 minims (0.20) of nitric acid at a dose, in water, will often 
be of service, but it should be taken through a tube to protect the teeth. 
In gastric indigestion in which, sometimes after a meal, undigested 
food regurgitates into the mouth, a few drops of nitric acid in water 
after meals will often give relief. In intestinal dyspepsia coining on 
some hours after meals, and in which not only discomfort but pain 
may be felt in the hypochondrium, nitric acid with some bitter tonic 
is most efficient, and it will often cure the green diarrhoea of children, 
particularly that met with in summer, bringing about these changes 
not only by its astringent power, but also by its stimulating effect on the 
intestinal glands. Combined with some good pepsin, it will give relief 
in the chronic diarrhoea of children associated with lienteru, and in which 
the stools may be pasty or watery and at the same time ill-smelling. 

Ringer recommends the employment of nitric acid in the treatment 
of piles. The strong acid should be used, and simply touched to one 
or two points, not swept over the whole surface. The pain is slight, 
or none at all may be felt. A slough results, and finally comes away, 
leaving a cicatrix which as it contracts diminishes the size of the pile, 

The same author also states that a lotion of nitric acid in the 
proportion of \ to 1 drachm to a pint (2.0-4.0 : 480 mils.) of water is 
of service in bleeding hemorrhoids, arresting the bleeding, constringing 
the parts, and relieving the sensation of weight and fulness so often 
a pressing symptom. 

The dose of dilute nitric acid (Acidum Nitricum Dilutum, B. P.) is 
3 to 15 minims (0.20-1.0), well diluted, and taken through a tube to 
protect the teeth. 

An exceeding strong preparation, Acidum Nitricum Fumans, is 
official in the B. P. 



392 



DRUGS. 



NITRITE OF POTASSIUM. 

Nitrite of potassium is a salt used largely in modern medicine to 
take the place of nitroglycerin, as it possesses greater stability, and 
is therefore more lasting in its effects (Fig. 56). It is used for the 



Fig. 56. 



Minutes 


Hour 


Hour 


Hour 


Hour 


Hour 


1 15 30 


1 


2 


3 


4 


5 



Hour 




Sodium 
Nitrite 
Nitro- 
glycerine 



Mannitol 
Nitrate 



Erythrol 
Tetranitrate 



Showing length of effect of different nitrites. 



relief of angina pectoris or heart-pang, in the treatment of gastralgia and 
in epilepsy. The dose is from 3 to 5 grains (0.2-0.3), although 
much larger doses have been employed. These larger doses are, 
however, not devoid of danger. Nitrite of potassium is eliminated 
by the lungs and by the kidneys as a nitrate. (See Nitroglycerin.) 

Cobalto-nitrite of Potassium, 

This preparation has been employed successfully as a substitute 
for the nitrite of potassium. As it is a more stable compound, it is 
less rapidly broken up in the system, and so exercises a more pro- 
longed influence. For this reason it does not act so vigorously or 
suddenly, which is a great advantage in some cases. Its use is identical 
with that of the rest of the nitrite group. The dose is J grain (0.03) 
every three hours. 



NITRITE OF SODIUM. 

Sodium nitrite (Sodii Nitris, U. S. and B. P.) is used for the same 
purposes as nitrite of potassium in the dose of 1 to 2 grains (0.06-0.12) 
given in pill or cachet. If exposed to the air it deliquesces, gradually 
oxidizes, and becomes unfit for use. This is probably the best of all the 
nitrite preparations for cases of persistent high arterial tension. It is 
best given in capsule with sodium bicarbonate. (See Nitroglycerin.) 



NITROGLYCERIN. 393 

NITROGLYCERIN. 

Nitroglycerin, sometimes called trinitrin or glonoin, is a compound 
which, in its pure state, is used largely as an explosive, but it is employed 
in medicine in a dilute form as a useful drug in those instances where 
a somewhat rapid and powerful effect is to be exercised over the vas- 
cular system. As its influence lasts but a short time, it should be given 
every three or four hours. Its physiological action is identical with that 
of the other nitrites, such as the amyl nitrite (which see), except that it 
is not so violent or fugacious as the latter nor so persistent in its effects 
as the nitrites of sodium and potassium. The dose is 1 to 2 minims 
(0.05-0.10) of a 1 per cent, alcoholic solution (Spiritus Glycerylis Ni- 
tratis, U. S. P.) in a little water or in a pill, after the patient has taken 
the remedy for a considerable period of time, as much as 60 minims 
has been administered, as the system rapidly becomes accustomed to 
its effects. Often good results are obtained only by giving ascending 
doses. It is noteworthy that patients rapidly become immune to the 
drug, and Reading has recorded a case in which, after a year of treat- 
ment, 1 drachm (4.0) of a 10 per cent, solution was taken daily with 
good effect. The author has given as much as 1 \ grains a day. 

The drug is largely employed in angina pectoris (see Part 
IV.), and sometimes in epilepsy and chorea and in gastralgia. 
J. M. Da Costa and others have highly commended this drug in 
the treatment of chronic parenchymatous nephritis, as it distinctly 
decreases the excretion of albumin from the kidneys. In interstitial 
nephritis, with cardiac disturbance resulting from the renal changes, 
in which there is a marked increase in arterial, pressure, so that auscul- 
tation reveals at the second right costal cartilage an accentuated second 
sound due to the forcible closure of the aortic leaflets, nitroglycerin 
often produces a good effect by reducing the pressure and relieving the 
heart of strain. This use of the drug is one of its most important appli- 
cations. (See article on Heart Disease, in Part IV.) It is when attacks 
of angina pectoris seem to be accompanied or preceded by marked 
vascular spasm that nitroglycerin is chiefly indicated. Nitroglycerin 
given hypodermically in the dose of tto to -^ grain (0.0006-0.0012) 
is one of the best remedies for haemoptysis. (See Amyl Nitrite.) 

In cases of asthma dependent upon spasm and engorgement of the 
mucous membranes of the bronchial tubes it is serviceable. Hum- 
phreys asserts that nitroglycerin is a most valuable drug in vomiting 
of all kinds, except that of pregnancy and peritonitis. Given in the 
dose of yto- grain (0.0003) hypodermically with morphine it prevents 
the after-nausea sometimes produced by that drug. 

Nitroglycerin usually causes a considerable increase in urinary 
flow by reason of the relaxation of the renal bloodvessels which it 
produces, particularly those vessels forming the Malpighian tuft. 

Because nitroglycerin relaxes arterial tension and so relieves the 
heart of a certain amount of labor in cases characterized by high 



394 DRUGS. 

arterial tension, thereby doing good when the heart is tired because 
of the labor required of it, many physicians have come to employ it 
as a cardiac stimulant in acute diseases without high tension of the 
bloodvessels. There is no justification for this use of the drug, for it 
is not a stimulant. 

The 1 per cent, solution used in medicine is too weak to be explosive. 
Tablets of nitroglycerin (Tabellce Trinitrini, B. P.) each contain 
tto grain (0.0005). The Spiritus Glycerylis Nitratis, U. S., is a 
1 per cent, alcoholic solution of glyceryl trinitrate. It should be kept 
in tightly stoppered tins, never in glass, and be stored in a cool place, 
away from heat. Its explosiveness is in direct ratio to the evaporation 
of its alcohol. If it is spilled in any quantity so that the alcohol can 
evaporate and so leave nitroglycerin in concentrated form it should 
be decomposed by pouring over it a solution of potassium hydroxide. 
The dose of the spirit is the same as that of the watery solution, 
namely, 1 to 2 minims (0.05-0.1). Liquor Trinitrini, B. P., is prac- 
tically identical with the spirit just named, and is given in the same 
dose. 

Erythrol Tetranitrate, 

Erythrol tetranitrate is a white crystalline substance, soluble in 
alcohol, but insoluble in water. It is explosive on percussion or 
trituration, and is employed in the place of nitroglycerin for the pur- 
poses just named. It is not so useful, however, and is slower in effect. 
Its dose is \ to \ grain (0.015-0.03), given in solution or in tablets. 



NITRO-HYDROCHLORIC ACID. 

Nitro-hydrochloric acid (Acidum Nitro-hydrochloricum, U. S.) is 
a liquid giving off a distinct odor, possessing caustic power, which 
stains the tissues of the body a light yellow. It is official in the 
form of the dilute acid (Acidum Nitro-hydrochloricum Dilutum, U. S. 
and B. P.), in which form it is useless except as an ordinary acid. 
When it is desired to use the acid for its own peculiar effects, the 
official dilute acid ought always to be supplanted by the freshly mixed 
strong acid, which should be of an orange color. If this cannot be 
obtained, the physician should prepare the compound himself by 
adding 4 parts of medicinally pure nitric acid to 16 parts of hydro- 
chloric acid, and allowing the mixture to stand in an open bottle until 
fumes are no longer given off in excess, when it should be tightly 
corked and kept in a dark place. This acid ought to be freshly pre- 
pared every few days. 

Poisoning. — The symptoms caused by poisonous doses are those of 
violent gastro-enteritis with vomiting and purging of bloody materials. 
Death may occur from perforation of the alimentary canal, from inflam- 
mation of the abdominal viscera, and from destruction of the peptic 



NITRO-HYDROCHLORIC ACID. 395 

tubules or constrictions of the oesophagus or bowel. The treatment 
consists in the use of alkalies, such as magnesia, lime, plaster, soap, 
and oils, with opium to allay irritation. The use of external heat to 
prevent collapse is also to be resorted to. 

Therapeutics. — Xitro-hydrochloric acid is an invaluable remedy in 
many cases of indigestion arising either in the stomach or bowels, 
as it acts as a tonic and stimulant to secretion. Upon the biliary 
flow its action is marked, and it may even cause bilious purging if 
administered in full doses for some days. It is therefore largely used 
in hepatic torpor, either acute or chronic, and in the early stages of 
hepatic cirrhosis should always be resorted to. In the chronic hepatitis 
of hot climates it is exceedingly useful, but it is not to be employed in 
acute sthenic hepatitis, as it is a stimulant to the liver, which, under 
these conditions, needs quieting. When used in chronic hepatitis it 
should be given in full dose and pushed to its physiological limit, 
as evidenced by the bilious purging produced or by signs of gastro- 
intestinal irritation. 

A useful additional means for obtaining the beneficial effects of 
this acid is to use it by means of the foot-bath or general bath. As 
used by Johnson in India, the acid for this bath is prepared by slowly 
and carefully adding together 2 parts of nitric acid and 3 parts of hydro- 
chloric acid, and after twenty minutes mixing carefully with these 
distilled water 5 parts. For a general bath (in a wooden tub) take 5 
pailfuls of water, 64 fluidounces (2 litres + ) of the acid mixture, and 
enough boiling water to raise the temperature to 98° F. Keep the 
patient in the bath twenty minutes. Then rub him thoroughly with 
warm towels and place him in a dry, warm bed. For the foot-bath 
add 6 ounces (180.0) of the acid to 2 gallons (7 litres) of water at 98° F., 
and bathe the thighs and calves of the legs for twenty minutes with a 
sponge wet with the mixture. This is a very useful treatment, accord- 
ing to Stille, for cases of alcoholic hepatic torpor. If in either case 
the skin becomes irritated, less acid is to be used. 

In ordinary so-called biliousness, which is not biliousness but intes- 
tinal indigestion, this acid is often of great service. (See Indigestion 
and Biliousness.) It is also of value in lienteric diarrhoea where the 
dysentery results from defective secretory action on the part of the 
glands which pour out the proper fluids for digestion, 

Another very important action of nitro-hydrochloric acid is the 
remedial influence, it exerts in persons suffering from oxaluria, par- 
ticularly if this be associated with melancholia or great mental de- 
pression. 

Administration. — The strong, freshly mixed acid should be given 
to the adult in the dose of 3 to 5 minims (0.20-0.3) three times a day, 
well diluted, and taken through a tube, after meals. If the patient is 
intelligent, he should be ordered \ ounce (16.0) of the pure acid and 
told how to drop it. If he is not, the physician should order it partly 
or entirely diluted in the prescription, and in so small an amount 



396 DRUGS. 

that it will be renewed before it loses any of its power. Warning 
should be given of its effects on clothing with which it may come in 
contact, and care should be taken that the bottle is held some dis- 
tance from the face when the cork is withdrawn, as the acid, if freshly 
mixed, may spurt and burn the eyes and skin. 

NITROUS OXIDE. 

Nitrous oxide, or Nitrogenii monoxidum, U. S., is sometimes called 
protoxide of nitrogen, or "laughing gas." Its power to relieve pain 
was first recognized by Sir Humphrey Davy more than one hundred 
years ago. As with ether, so with nitrous oxide, its first use as a 
surgical anaesthetic was by an American, Horace Wells, a dentist. 

This gas is obtained by a complicated process which requires the 
use of such cumbersome apparatus that its manufacture is out of the 
question for the ordinary practitioner of medicine, while the fact that 
several firms prepare the gas and market it in cylinders ready for 
use renders its preparation on a small scale unnecessary. The gas is 
devoid of odor, but possesses a slightly sweet taste. It may be kept 
in gaseous form, or in liquid form and allowed to become gaseous as 
it is used. Owing to the symptoms sometimes produced in persons 
inhaling this gas, it has received the popular name of "laughing gas," 
but a condition of hilarity is rarely seen when the inhalations are full 
and deep, and only comes on, in the majority of cases, when the gas 
is given in small amounts or inhaled very slowly. 

Physiological Action. — According to some careful studies upon 
the action of this gas (Kemp), it has no direct effect on the heart and 
vasomotor system, but indirectly it causes a rise of arterial pressure 
by the slight asphyxia which is produced. The anaesthesia is due in 
part to the non-oxygenation of the blood during the time the gas is in 
this fluid, but the gas chiefly produces anaesthesia by a direct action on 
the cerebral cortex. It is a curious fact that the conjunctival reflex is 
often preserved after general anaesthesia is present. It has been thought 
that the use of this drug produces temporary glycosuria, but recent 
studies render this doubtful, to say the least. When permanent glyco- 
suria has been produced, some injury to the vascular system in the 
region of the diabetic centre in the floor of the fourth ventricle has in 
all probability occurred. Nitrous oxide gas rarely produces any dis- 
agreeable after-effects, save a slight light-headed sensation or dizziness 
lasting for a few hours. 

Therapeutics. — When used properly, the patient is directed to take 
long, deep inspirations from the tube placed in the mouth, the nose 
being held so that the nostrils are closed, or a mask, provided with a 
valve for the escape of the expired air, is applied over the mouth and 
nose. The gas is then allowed to enter the mask and is inhaled from 
it. Under these circumstances the face becomes for a moment flushed, 
then of a deadly pallor, and finally the jaw drops if the effect is com- 



NITROUS OXIDE. 397 

plete. At this time anaesthesia is complete and the operation is to be 
rapidly performed. 

Owing to the fact that when pure it is devoid of depressant effects 
and irritant properties, this gas can be used when ether and chloroform 
are contraindicated. 

Nitrous oxide is a useful anaesthetic in all minor operations, such 
as opening an abscess, boil, or felon, or even amputating a digit. It 
is used by many surgeons at the present time for the purpose of begin- 
ning an anaesthesia which is to be continued by ether or chloroform, 
since the rapidity with which it produces anesthesia prevents the 
disagreeable preliminary symptoms induced in many persons by these 
drugs. This is particularly advantageous in nervous women and chil- 
dren. The gas possesses two disadvantages : the first of which is its 
brevity of action, the other the difficulty in carrying it from place to 
place. It possesses a great advantage in almost absolute safety, very 
few deaths having been caused by it directly. It is the safest of all 
anaesthetics, not even excepting cocaine, which latter drug has largely 
supplanted the gas for many minor surgical operations. 

When teeth are to be extracted, a plug or cork is placed between 
the jaws before the gas is given to keep them apart. The cork 
should always be attached to a string, so that if it slips into the 
back part of the mouth it can be withdrawn before it chokes the 
patient. Jaw forceps may also be employed. 

The combination of nitrous oxide and oxygen-gas is becoming 
more and more popular for many major operations, since the oxygen 
enables the anaesthetist to prolong the anaesthesia almost indefinitely 
and the patient is never more than "just under." So far as surgery 
is concerned, the use of nitrous oxide alone has been almost completely 
supplanted by the use of the combined gases. Particularly is it 
useful if very weak solutions of some local anaesthetic like Schleich's 
fluid or a 0.25 per cent, procaine solution is used, the entire field 
of the operation as it proceeds being infiltrated as nearly as possible 
along the lines of its nerve supply. Many physicians, particularly 
those attached to maternities or hospitals in which assistants trained 
in the use of this gas are present, are using with good results nitrous 
oxide gas to relieve the pains of childbirth. If given skilfully there 
is no danger to the mother and but little danger to the child. Asphyxia 
of the newborn may be present if it is carelessly used. Many anaes- 
thetists use an apparatus by which nitrous oxide, oxygen and ether 
can all be used. (See Fig. 57.) 

The following classes of persons, according to Hewitt do better with 
the mixture of oxygen and nitrous oxide than with the nitrous oxide 
alone: 1. Children (who, with nitrous oxide alone, are liable to incon- 
venient jactitation). 2. Anaemic and debilitated patients, who, like 
children, quickly exhibit muscular contraction, and in addition to 
this, remain but a very short time under the influence of nitrous oxide 
alone. 3. Anyone who has previously exhibited great insusceptibility 



398 



DRUGS. 



to nitrous oxide per se (such patients are difficult subjects to manage 
in dental practice because of the short period of available anaesthesia) . 
4. Patients who, under nitrous oxide alone, have experienced highly 
unpleasant sensations. 5. Patients very advanced in years. 6. 
Patients with very large tonsils. 7. Patients suffering from heart or 
lung affections. 

Fig. 67. 



ETHER INTAIM 



♦•DROP REGULATOR 7 



OXYGEN CONTROL 
VALVE 




JIPIJP 



n2o control 

VALVE 



n2o EXPANDING 
CHAMBER 




SArET.^ HEATEI 



Nitrous oxide-oxygen-ether apparatus assembled for use. (Connell.) 

Administration. — More training and skill are needed to produce 
satisfactory anaesthesia for surgical purposes by nitrous oxide than 
when ether is employed. When nitrous gas is used as an anaesthetic it 
must be given without any air being admitted to the inhaler. The 
inhaler fits closely to the face and by means of valves the gas gains 



NOSOPHEN. 399 

access to the lungs during inspiration, but during expiration the expired 
air and gas escape into the room or into a rubber bag so that rebreath- 
ing may be practised. Whenever it is desirable to continue nitrous 
oxide anaesthesia for more than a few moments, it is advantageous to 
combine with the nitrous oxide gas a small proportion of oxygen, 
since in this way asphyxia is prevented. The oxygen gas, however, 
must be given moderately or it will interfere with the full effects of 
the nitrous oxide. These gases are best administered by some such 
apparatus as that shown in Fig. 57. Two of the tanks (colored red) 
contain pure oxygen and the others (colored blue) are filled with 
nitrous oxide. 

Under the openings marked "oxygen meter" and "N 2 meter." 
which are covered with glass, there are disks, each of which is actuated 
by the flow of gas. On the periphery of each disk there is a scale 
which enables one to judge the rate of gas flow. The disk measuring 
the oxygen flow is calibrated to a flow in steps of 0.1 litre per minute 
up to 2.5 litres per minute. The nitrous oxide disk is calibrated in 
steps of 1 litre per minute up to 12 litres per minute. The calibra- 
tion of the disks differs because the amount of oxygen employed is 
far less than that of nitrous oxide. By these disks the quantity of 
the oxygen and nitrous oxide which a patient is receiving can be 
estimated, and the quantities varied according to the degree of anaes- 
thesia and the condition of the patient. By means of the stop-cock 
shown in the illustration ether can be added to the gases and, by 
means of the "safety heater," the ether may be warmed without 
danger of exploding. During anaesthesia a flow of oxygen amounting 
to about 0.5 litre per minute is usually employed, but larger quanti- 
ties may be used if need be. The nitrous oxide is usually given at the 
rate of from 6 to 10 litres per minute. 

If the operation is a prolonged one, it is advisable to permit some 
atmospheric air to enter at the sides of the inhaler occasionally, in 
addition to the oxygen. 

Contraindications. — The gas ought not to be given to those who are 
advanced in years or have atheromatous bloodvessels, since the rise 
of arterial pressure consequent upon the asphyxia may rupture a 
cerebral bloodvessel and thereby cause an apoplexy; but if oxygen 
gas is properly given with it this danger is largely put aside, for except 
in rare cases the pressure does not rise. 

NOSOPHEN. 

Xosophen is a substance obtained by the action of iodine on solutions 
of phenolphthalein, and is a light impalpable powder, without taste or 
odor, and of a yellowish-gray color. It is said to contain 61.7 per cent, 
of iodine. Nosophen is insoluble in nearly all solvents, but is soluble 
in alkaline solutions, and with alkalies it forms salts. The uses of this 
substance are practically identical with those of iodoform in that it 



400 DRUGS. 

exercises a favorable effect on tissues by reason of its content of iodine 
and drying properties. Its bulk is four times greater than an equal 
weight of iodoform. When used as an antiseptic on sores it should 
be brought directly in contact with the living tissue, and not simply 
applied to the pus or scab covering the part. As it will withstand 
a high heat, it can be sterilized by exposure up to 220° F. without 
decomposition. Its lack of odor is a great advantage. 



NOVASPIRIN. 

Novaspirin is a white powder possessing a faint acidulous taste, but 
without odor. It is practically insoluble in water, but readily so in 
alcohol. It contains 62 per cent, of salicylic acid and its chemical 
name is methylene-citryl-salicylic acid. As it is supposed to pass 
through the stomach unchanged, it may be employed interchangeably 
with salol or aspirin when the gastric disturbances produced by the 
ordinary salicylates contraindicate their use. When it comes in contact 
with the alkaline juices of the intestines it is decomposed into salicylic 
acid and methylene citric acid. It is less irritating than aspirin. 

The uses of novaspirin are practically identical with salol and 
aspirin, namely: in influenza, tonsillitis, intestinal fermentation, neu- 
ralgia, and in both muscular and acute articular rheumatism. 

The ordinary dose for an adult is from 8 to 15 grains (0.5-1.0). 
As much as 60 grains (4.0) or more may be given in twenty-four 
hours, if necessary, to combat rheumatism. 



NOVATOPHAN. 

Novatophan is 6 methyl-, 2 phenyl-quinolin, 4 carboxylic acid ethyl 
ester. It is an almost colorless, tasteless, crystalline powder, insoluble 
in water, but readily soluble in alkalies or hot alcohol. A number of 
investigators have proved that it greatly increases the elimination of 
uric acid and it undoubtedly relieves pain in gouty and lithamiic per- 
sons, but that it is directly useful in the cure of gout is undecided, for 
gout is something more than the mere formation and retention of uric 
acid in excess. The increase in the elimination of uric acid is, however, 
due chiefly to the action of the drug on the kidneys. It does not 
mobilize deposited urates. 

Novatophan is best given in tablets or capsules, or powder stirred 
in water after meals and at bedtime being washed down with a full 
draught of water, preferably Celestin Vichy water, or water contain- 
ing sodium bicarbonate. The ordinary single dose is 7 to 10 grains 
(0.5-0.65). Atophan, now called Acidum Phenyl Cinchonicum, has 
an identical effect, but is more apt to disturb the stomach. 



NUX VOMICA. 401 

NOVOCAINE. 

(See Procaine.) 
NUTMEG. 

Myristica, U. S. and B. P., or nutmeg, is the kernel of the ripe seed 
of Myristica fragrans, an East and West Indian plant, mace being 
the outside covering of the same. Nutmeg is a soporific and nervous 
sedative, exercising a peculiar influence over the cerebrum. It is also 
used as a flavoring substance in somnifacient mixtures, and is of value 
in prescriptions for serous diarrhoea. The oil (Oleum Myristica', U. S. 
and B. P.) is given in the dose of 1 to 3 minims (0.05-0.20). The 
spirit or essence (Spiritus Myristica") is used in the dose of 1 to 2 
fluidrachms (4.0-8.0). 

Several instances of poisoning by nutmeg are reported; a severe 
case by Dr. Reading, of Woodbury, N. J. The symptoms closely 
resemble those produced by excessive doses of cannabis indica. 



NUX VOMICA. 

Nux vomica (U. S. and B. P.) is the seeds or beans of Strychnos 
Nux-wmica, an East Indian tree, yielding when assayed by the U. S. P. 
process not less than 2.5 per cent, of the alkaloids of nux vomica. It 
contains two alkaloids, strychnine and brucine, and depends largely 
for its medicinal power on the former. For this reason the statements 
made in regard to the physiological action of strychnine may practically 
be considered as applicable to the entire drug. 

Physiological Action.— When strychnine is given to man or the lower 
animals in full medicinal dose it increases reflex activity, respiratory 
rate, pulse-force, arterial pressure, the acuity of smell, vision, and 
hearing, and causes general systemic irritation or excitement. 

Nervous System.— On the nervous system strychnine exerts its 
chief influence. It excites the spinal cord in its motor tracts, and 
probably increases the receptive activity of the sensory centres. It 
also has some slight influence in increasing the conductive power of 
the motor and sensory nerves. 

In overdose strychnine produces spinal or tetanic convulsions by 
an action exerted on the spinal cord. When enormous doses are 
given intravenously, total paralysis, resembling that caused by curare, 
precedes the convulsions, and if artificial respiration is not used the 
animal dies from failure of respiration. If death takes place from the 
effects of the drug, the motor nerves are found to be depressed, partly 
as the result of the poisonous action of the strychnine, and partly as 
the result of the exhaustion of the nerve-trunks by the convulsing 
impulses which they have carried (Fig. 58) , 
26 



402 



DRUGS. 



Fig. 58. 



Circulation. — Nux vomica increases the force of the pulse-beat 
and the pulse-rate by a stimulation of the heart-muscle and its glanglia, 

while the rise of arterial pressure which 
it causes is due to stimulation of the vaso- 
motor centre. If very poisonous doses 
are injected intravenously, a fall of arterial 
pressure occurs instead of a rise, which is 
due to vasomotor depression and paralysis. 
Respiration. — Strychnine is one of the 
most constant and powerful stimulants of 
the respiratory centre that we have, and 
it not only increases the rate of respira- 
tion, but also the respiratory capacity. 

Temperature. — Ordinary doses have 
no effect upon temperature, but poisonous 
doses may raise it by reason of the con- 
vulsions. 

Elimination. — Strychnine is elimin- 
ated from the body by the kidneys as 
strychnine and strychnic acid. Most of 
it is oxidized and destroyed by the liver. 
Therapeutics. — Nux vomica, or its chief 
alkaloid strychnine, is used for several 
purposes in medicine. Owing to its bitter 
character, it may be employed as a simple 
bitter tonic or as one especially influencing 
the nervous system. It may also be used 
as a respiratory, cardiac, and ocular 
stimulant. 

In cases of functional nervous atony, or 
depression, strychnine does good; but in 
organic disease of the nervous system, if 
used during the period of acute inflam- 
mation, as, for example soon after an 
apoplexy or in acute infantile palsy, it is distinctly harmful. Some 
persons who have suffered from apoplexy can never take the drug without 
a spasm coming on in the paralyzed part or parts, probably through 
irritation of the degenerated pyramidal tracts. In acute or subacute 
neuritis strychnine ought never be used, as the nerves are already 
inflamed, and are not to be still further irritated by the employment of 
nerve excitants. In progressive lead palsy large doses of strychnine 
should be constantly used to check the progress of the disease, 
iodide of potassium also being employed to cause elimination of the 
lead. 

In amaurosis dependent upon the excessive use of tobacco or alcohol 
strychnine is almost a specific, and in eye-strain resulting from insuffi- 
ciency of the ocular muscles it does great good, curing the insufficiency 




A , nux vomica stimulates the motor 
tracts in the spinal cord and to a slight 
extent the nerve-trunks; B, in large, 
poisonous doses it depresses the motor 
nerve-plate in the muscle and exhausts 
the nerve-trunks. 



NUX VOMICA. 403 

and improving the general condition of the muscles. According to 
de Schweinitz, the patient should use ascending doses of the tincture 
of nux vomica, beginning with 10 minims (0.65) three times a day, and 
increasing the amount 2 minims (0.1) a dose until distinct physiolog- 
ical effects are produced. Sometimes 60 minims (4.0) or more may be 
taken in twenty-four hours. 

Experiments by the author indicate that constantly increasing doses, 
instead of decreasing the person's susceptibility to the drug, actually 
increase it, so that a large but moderate dose produces greater effects 
after some days of use than a full dose does at first. 

In pneumonia and all other acute diseases in which sudden collapse 
is liable to occur strychnine is of the greatest service at the time of 
need. Often it will pull the patient out of a sinking attack which 
seems certain to end in death. It should be used freely by the hypo- 
dermic needle, and is often aided in producing its good effects by the 
addition of jj^ to j-J-g- grain (0.0004-0.0006) of atropine to each injec- 
tion. (See Pneumonia and Shock.) 

The author desires to protest most emphatically against the common 
oractice of the dav, which consists in the use of strvchnine as a cireu- 
latory stimulant through prolonged exhausting illness. It is essentially 
a wmip to the flagging heart, to be used at a crisis, but not continued 
for days. Cases are constantly seen in which the persistent use of 
the drug in fever produces a rapid running pulse and great nervous 
irritation and prolongation of the febrile movement. 

There is no drug known which is so antidotal to the effects of over- 
doses of chloroform as is strychnine. In cases of sudden accident, with 
arrest of the heart or respiration during the use of this anaesthetic the 
physician should give an intra-muscular injection of j-q grain (0.006) 
of strychnine as a powerful, rapidly acting cardiac and respiratory 
stimulant, which dose may be repeated in ten minutes if no effect is 
produced. 

The use of strychnine as a stimulant in surgical shock has been 
criticized on the ground that it is valueless if the vasomotor centre is 
paralyzed. This would hold true if the centre was paralyzed ; in most 
cases, however, it is only depressed, and strychnine does good if the 
operation or accident is past. Given before operation to prevent shock 
its use is unwise in that, by stimulating and exciting the nervous sys- 
tem, it renders it more susceptible to shock and injury. Oftentimes 
the apparent collapse of a recuperating patient is due rather to intense 
nausea than to the shock, and the free use of this drug is not necessary. 

It is a better antidote to opium than is belladonna. 

In dyspnoea from any cause, such as that of old persons suffering 
from winter cough or bronchorrhcea, in emphysema, phthisis, and in 
shortness of breath, strychnine is of service, and it is a valuable drug 
for the treatment of opium poisoning, because it preserves the reflexes 
and stimulates the respiratory centre. 

In atony of the bowels strychnine is of service, and it is to be. 



404 DRUGS. 

added to purgative pills to avoid their depressing after-effect on the 
intestines. 

In cases of hemiplegia, strychnine may be used to keep up the nutri- 
tion of the limbs, which are paralyzed; but if the paralysis be due to 
disease of the trophic cells in the spinal cord, it does little good except 
to stimulate the remaining cells to greater effort. 

According to Ringer, sick headaches, due to errors in diet and without 
much nausea, can be relieved for the day by the use of 1 minim (0.05) 
of the tincture of nux vomica in a teaspoonful (4.0) of water every five 
or ten minutes until 10 minims (0.60) are taken. 

Strychnine possesses no curative properties in chronic alcoholism. 
Owing to its powerful stimulant properties it may temporarily brace 
the nervous system, but its prolonged use is dangerous. It should be 
employed temporarily only to combat great depression of the system. 

Untoward Effects. — Care should be exercised in giving strychnine 
to children, as they are more susceptible to the drug than are adults. 
The proper beginning dose of strychnine by the mouth for a child of 
five or six years is not more than y^j- grain (0.000G). In some cases 
of exhausting disease the prolonged use of full doses of strychnine may 
produce a talkative delirium with great peevishness, and, if the drug is 
continued, this condition may pass into a state of temporary insanity. 
Brunton asserts that nux vomica may induce malarial chills in those 
predisposed to them. He also asserts that strychnine acts more power- 
fully when given by the rectum than by the mouth. This is doubtful. 

Administration. — The extract of nux vomica (Extractum Nucis 
Vomica?, U. S., and Extractum Nucis Vomica? Siccum, B. P.) should 
contain about 16 per cent, of alkaloids and is given in the dose of | to 
1 grain (0.01-0.015), i to 1 grain (0.015-0.06), B. P.; the fluidextract 
(Fluidextractum Nvcis Vomica?, U. S., Extractum Nucis Vomica? 
IAquidum, B. P.) contains about 2.5 Gm. of alkaloids in 100 mils., and 
is given in the dose of 1 to 5 minims (0.05-0.3); the tincture {Tinctura 
Nucis Vomica 7 , U. S. and B. P.), containing about 0.25 Gm. of alka- 
loids in 100 mils., is used in the dose of 5 to 30 minims (0.3-2.0), 5 to 
15 minims (0.3-1.0), B. P. Strychnines Sulphas (U. S.), StrychnincB 
Nitras (U. S.), and Strychnine Hydrochloridum (B. P.) are given hypo- 
dermically in the dose of -3V to 2V grain (0.002-0.003), and by the 
mouth in the same amounts. In cases of severe surgical shock as much 
as i grain (0.015) may be used hypodermically. The B. P. recognizes 
a solution (Liquor Strychnines Hydrochloride ; dose, 2 to 8 minims 
(0.1-0.5). 

Poisoning. — When a poisonous dose of strychnine is taken, it may act 
either suddenly or gradually. If suddenly, the man or animal may, 
without premonition, be thrown several feet and become rigid by con- 
traction of the muscles. If onset is gradual, some stiffness at the back 
of the neck and uneasy startings may precede the general nerve- 
storm. 

The convulsions are tetanic, or, in other words, tonic, and the 
body is thrown into opisthotonos: that is, resting on the head and 



NUX VOMICA. 405 

heels at each convulsion. Rarely the trunk is twisted sidewise or the 
flexion of the body is forward (emprosthotonos) . The eyes are open 
and fixed, the corners of the mouth drawn back into risus sardonicus. 
and respiration during a severe convulsion is impossible owing to the 
respiratory muscles being in a state of tetanic rigidity. 

The slightest noise, draught of air, or touch may cause a convulsion 
or convulsion after convulsion, because the sensory impulse, reaching 
the spinal cord, causes a spasmodic motor impulse to be sent out to 
the muscles. 

The convulsions are not absolutely continuous, but periods of utter 
or partial relaxation occur, during which the patient breathes easily. 
The cramp-like contractions of the muscles are exceedingly painful. 
The patient either dies of cramp asphyxia — that is, through failure 
of respiration because his chest muscles are locked in spasm — or, much 
more rarely, from exhaustion. After death the posture of the body 
may or may not be typical of the strychnine spasm. Usually it is not 
typical, although the severe muscular exertion of the attack may result 
in the early development of marked rigor mortis. Reichert has shown 
that it requires five hundred times the ordinary fatal dose of strychnine 
to cause death in animals if artificial respiration is properly main- 
tained. The average fatal dose for an adult is lj to If grains (0.10- 
0.12). Death has occurred from \ grain (0.03) and recovery after 
swallowing 19 grains (1.25). Hewlett has recorded a case in which 
15 grains (1.0) were swallowed yet recovery ensued. 

Treatment of Poisoning. — The attendant should give at once, if no 
symptoms have appeared, inhalations of nitrite of amyl, and mean- 
while employ the stomach-pump, using the nitrite to prevent any con- 
vulsive tendencies during the operation. Draughts of water containing 
tannic acid, as the chemical antidote, are to be administered, and 
after the stomach is washed out 60 grains (4.0) of bromide of potas- 
sium and 20 grains (1.3) of chloral in solution are to be given. These 
are the physiological antidotes, for the bromide of potassium depresses 
the sensory tracts of the spinal cord, and the chloral depresses the 
motor tracts. If the convulsions prevent swallowing, the patient should 
be chloroformed with care, and the physiological antidotes given in 
starch-water by the rectum, muscular relaxation being maintained by 
the anaesthetic until the drugs are absorbed. Ether cannot be used 
as a relaxant, as it is too irritant and too slow. Nitrite of amyl is 
a physiological antidote, but it is useless if a complete convulsive 
attack is present, as it cannot be inhaled if the chest is immovable. 
Neither can any other relaxant, such as chloroform, be used under 
these circumstances. These drugs should be gently given between the 
paroxysms. If relief does not occur, the nitrite of amyl should be 
injected hypodermically. Cutler and Alton have shown that intra- 
spinal injections of magnesium sulphate are advantageous. (See 
Magnesium Sulphate.) 

While a light touch may produce a spasm, it is said that a firm, 



406 DRUGS. 

hard grasp of the limb often relieves the pain of the cramp. Sensation 
and consciousness are preserved in strychnine poisoning unless the 
asphyxia obtunds them. 

Differential Diagnosis.— The convulsions of strychnine-poisoning 
do not resemble those of epilepsy, because they are distinctly tonic and 
never clonic. From tetanus, strychnine poisoning is to be differentiated 
by the fact that in tetanus the locking of the jaws comes first, while 
in strychnine poisoning it comes last. The convulsions of tetanus 
rarely, if ever, completely relax, while those of strychnine do have 
periods of relaxation. There is a different history in each case — in 
one perhaps of an injury, as of a nail run into the foot; in the other, 
of a dose of poison having been swallowed. 

The differential diagnosis of strychnine poisoning from hysterical 
convulsions is more difficult. The convulsions are rarely so persist- 
ently tonic in hysteria, and the peculiar expression of the hysterical 
face is often seen in such cases. The history of the patient, if obtain- 
able, will throw much light on the case and aid very materially in the 
differentiation of the two conditions, while the peculiar variations in 
cutaneous sensibility, such as areas of hyperesthesia and anaesthesia, 
which are so characteristic of hysteria, may render the diagnosis 
possible. 

As the treatment of all these states is virtually identical, the employ- 
ment of the measures just suggested may be resorted to in each instance, 
and the diagnosis made afterward. 



OPIUM. 

Opium (U. S. and B. P.) is the juice or milky exudation appear- 
ing on the surface of the unripe capsules of white poppy, or Papaver 
somniferum, a native plant of Asia, now grown in many other parts of 
the world. 

Good opium, according to the U. S. P., should contain at least 9.5 
per cent, of anhydrous morphine. 

The chemical composition of this drug is very complex, no less than 
seventeen alkaloids having been obtained from it, the most important 
of which are morphine, codeine, narcotine, thebaine, narceine, papav- 
erine, pseudomorphine, and laudanine. It also contains meconic acid 
and meconine. 

Physiological Action. — The action of opium upon man and the lower 
animals varies with the degree of intelligence or cerebral development. 
It quiets the brain and excites the spinal cord. 

Nervous System. — The dominant action of opium upon man is to 
produce nervous sedation in small doses and sleep when given in larger 
amounts. Sometimes, however, in persons who are accustomed to its 
use, it produces a state of restless insomnia or quiet, wakeful apathy. 
When given to frogs, it often produces tetanic convulsions, owing to its 



OPIUM. 407 

primary stimulant effect on the spinal cord. In dogs it increases the 
reflexes and produces drowsiness, and in man, sleep. If, however, the 
patient be a member of one of the lower races or a young child, the 
spinal irritation may be as manifest as the cerebral sedation. If large 
doses are given, sleep is produced in all animals, and both the 
brain and spinal cord are depressed. The sensory nerves are also 
markedly benumbed, and the motor nerves may finally be rendered 
inactive. 

Circulation. — Small therapeutic doses of opium have no effect 
upon the circulation, but large ones primarily slow the pulse, increase 
its force, and slightly raise arterial pressure. 

The slowing of the pulse depends upon stimulation of the pneumo- 
gastric nerves peripherally and centrically; the increase in pulse-force 
results from the stimulation of the heart-muscle; the rise of pressure 
is due chiefly to the increased heart-action. 

After poisonous doses the pulse becomes rapid and feeble, due to 
depression of the vasomotor centre and the heart, and the gradually 
increasing asphyxia. 

Respiration. — In very minute doses opium is a feeble stimulant, 
or at least not a depressant, to the function of respiration. In over- 
dose it is one of the most powerful paralyzants of the respiratory centres 
in the medulla oblongata, causing death by this action. 

Temperature. — The bodily temperature is raised slightly by full 
doses and lowered by poisonous amounts of opium. 

Tissue- waste. — Opium acts as a preventive to tissue-waste, decreas- 
ing the elimination of urea and other results of nitrogenous breakdown. 

Elimination. — If given in excess, the drug escapes from the body 
as morphine, by way of the intestine and kidneys, but most of it is 
destroyed by oxidation in the liver and tissues. Experiments made 
by Alt and Tauber show that morphine is largely eliminated by the 
stomach, and that if this viscus is frequently washed out during a case 
of poisoning, recovery is much aided, as by this means resorption is 
prevented. 

Pupils. — The myosis caused by morphine is often ascribed to depres- 
sion of the dilator portion of the pupillary centre situated in the medulla, 
but the existence of such a centre is purely hypothetical, and it is prob- 
able that the older teaching, to the effect that the myosis is due to 
centric oculomotor stimulation, is correct. 

Stomach, Intestines, and Secretion. — Opium depresses the 
motor activity of the stomach and intestines and produces constipa- 
tion. It does this by stimulating the splanchnic inhibitory fibres of 
the intestine and thereby preventing peristalsis. In very large doses 
it increases peristalsis by paralyzing these fibres. 

Opium checks every secretion in the body except that of the skin. 

Acute Poisoning. — When opium is taken by man in overdose, it 
causes drowsiness, deep sleep, full breathing, a slow, full pulse, a 
warm, dry skin, contracted pupils, and pleasant — or, more commonly 



408 DRUGS. 

in the Anglo-Saxon race, disagreeable — dreams or no dreams at all. 
Preceding this period there may be a brief one during which the 
individual feels self-satisfied and contented. The duration of this agree- 
able sensation lasts only a short time, and if the dose is large does 
not occur or is evanescent. It has been called the first stage, while 
the more marked symptoms just described have been grouped into a 
so-called second stage. 

During the sleep of the second stage the patient may be roused by 
shouting in his ear or by violent shaking, but sinks into slumber at 
once when not disturbed. 

Many of the symptoms resemble those of congestion of the brain. 
The iace is suffused and reddened, and may be finally distinctly 
cyanotic. The breathing may be puffing and stertorous. When the 
patient is awakened, he breathes more rapidly, and for this reason the 
duskiness of the face disappears and the normal hue returns. Death 
never occurs in the second stage of opium poisoning from the poison 
alone, but if a complicating disease is present death may take place 
at this time. 

The third or fatal stage emerges from the second by a process so 
gradual that no abrupt line of separation can be noted. The face 
becomes at first more cyanotic, then pale and livid; the respirations, 
which have been 8 to 10 to the minute, are now only 4 to 5, and finally 
such prolonged pauses occur that all hope of another respiration is 
lost by the attendant. While the slow breathing is at first deep, it 
soon becomes shallow, and muscular relaxation is present to the greatest 
degree. The skin, previously dry, is wet with the sweat of death, 
the patient is so deeply narcotized that nothing can arouse him, and he 
dies from respiratory failure, although the heart may cease almost 
simultaneously from the asphyxia. The pupils do not dilate in the 
third stage, except in the relaxation of death. 

Treatment of Acute Poisoning. — After employing the usual 
methods resorted to for the purpose of emptying the stomach, and 
after giving permanganate of potassium or tannic acid, preferably 
the former, as the chemical antidote, the patient should receive by 
the rectum one or more cups of black coffee, hot and concentrated. 
The heat in the liquid is useful in maintaining bodily temperature, 
and the caffeine stimulates the respiratory centre and keeps the patient 
awake. Coffee should be used even before any symptoms come on, in 
order to prevent their onset if possible. If strychnine is at hand and the 
respirations are becoming very slow, -£$ to -^ grain (0.002-0.006) should 
be given hypodermically. Strychnine is much better than atropine as 
an antidote to opium, and should be given hypodermically in full dose, 
repeated frequently enough to keep the nervous system of the patient 
active and respiration intact. The pupil is no guide as to the action of, 
atropine in opium poisoning, as the influence of these two drugs (opium 
and atropine) on the eye is not directly antagonistic. Cocaine is thought 
by some physicians to be a satisfactory physiological antidote to 
opium. 



OPIUM. 409 

Alcoholic stimulants may be called for, and ammonia as a cardiac 
and respiratory stimulant may be resorted to. 

In the third stage heat should be applied to the trunk and extrem 
ities. 

Much emphasis has been placed on keeping the patient awake, 
and it has been thought that the cause of death was the deep sleep. 
This is not so. The man must be kept awake in order that he will 
supplement the efforts of his depressed respiratory centres by volun- 
tary breathing. If he sleeps, he forgets to breathe, and sleep means 
death for this reason, and not because sleep in itself produces death. 

Fig. 59. 




A, Opium produces sleep by depressing the intellectual centres of the brain, and B, relieves pain by- 
depressing the perceptive centres in the brain. 

Besides the use of hot strong coffee, the patient may be kept 
awake by lashing him with switches or by walking him up and down 
between two attendants. Both of these measures are reprehensible 
if anything better can be done— the first method because it covers 
the patient with cuts and bruises, the second because it may aid in 
the production of death by exhaustion. If an ordinary medical 
faradic battery is at hand, the full force of the current may be allowed 
to come in contact with the skin from two small poles wet with salt 
water, or, better still, the dry or wire electric brush should be swept 
over the body while the negative pole is held in the hand of the patient or 
pressed against his skin. This causes the most exquisite pain in the normal 
individual, but if the brush is kept moving will not cause bruises or dis- 
coloration. (See Asphyxia.) Artificial respiration may be resorted to. 

As pointed out when discussing the elimination of opium, the 
drug is eliminated into the stomach from the bloodvessels and then 
reabsorbed. Frequent washing out of the stomach is therefore advis- 
able in cases of poisoning. 

Chronic Poisoning. — Morphine or opium when taken constantly 
generates a habit. The person — or morphine-habitue, as he is some- 
times called — depends for a comfortable existence on the drug, and 
day by day increases the dose until the most extraordinary amounts 
are taken by the stomach or by means of the hypodermic needle. This 
ability to take large doses depends upon an increased ability on the 
part of the body to oxidize the poison. A full dose given to an ordinary 



410 DRUGS. 

person results in the escape by the bowels of a large percentage of 
it, but if gradually increasing doses are given, no trace of even large 
doses are obtainable in the stools or urine. If the drug is withheld 
from the morphine habitue, a train of symptoms typifying depression 
or exhaustion ensues. The pulse is scarcely to be felt, horrible mental 
depression and melancholia come on, the miserable man or woman 
wrings his or her hands, and begs, screams, howls, or yells for mor- 
phine, only to break down and cry on being refused the customary dose. 
Diarrhoea of a serous type and most violent in character, with cramps 
in the muscles, may assert itself, and must be controlled by astringents 
and camphor, and an active line of treatment, as far as possible free 
from opium. (See Diarrhoea.) 

A characteristic symptom of chronic opium-eating is the develop- 
ment of the most clever lying in previously truthful persons. In the 
same breath that the patient begs the physician to cure him, he will 
lie to obtain the drug in a surreptitious manner, and may even have 
the drug in his mouth at the moment he speaks. It will often be 
found hidden in the seams of the clothing, and the nurse must be 
absolutely reliable, above bribery, and forever on the watch lest the 
drug be obtained by smuggling. Any sudden improvement on the 
part of the patient should be placed to the credit of more morphine, 
not to professional skill. 

The well-known fact that certain races of mankind are affected 
by some drugs in quite a different manner from that exerted upon 
the white race finds an interesting confirmation in the opinion ex- 
pressed by physicians and government officials, who have investigated 
the subject in India and China, that a large number of Orientals use 
opium in moderation for years without deleterious effects. They 
remain well nourished, are able to perform labor requiring severe 
physical exertion, and the death rate among them is not higher than 
among other classes of people. 

Sometimes paregoric is taken in excess, and the writer has seen and 
treated a case in which over a pint of paregoric was taken every day. 

When a mother is an opium-eater, the newborn child often suffers 
from collapse on the second or third day after birth, owing to the lack 
of its customary dose of opium. 

Treatment. — The best way to decrease the use of the drug is to 
" taper off" the daily dose, and to decrease by a sixth or a fourth 
the total customary amount in each twenty-four hours. The sudden 
complete withdrawal of the drug is an unnecessarily severe measure, 
and its withdrawal in a slower manner than that named is simply 
prolonging the treatment beyond resonable limits. 

It is essential at the beginning of the withdrawal that the liver and 
bowels be thoroughly unloaded by 5 grains of blue mass and 10 to 20 
grains of compound extract of colocynth. 

A very valuable means of treatment is the use of massive doses of 
hyoscine hypodermically. If this plan is followed, the morphine may 



OPIUM. 411 

be sometimes withdrawn at once. (See Hyoscine.) If the circulation 
Hags, digitalis and strychnine may be given and the remaining symp- 
toms treated as common-sense indicates. Cocaine has been unwisely 
used to tide over the crisis after the withdrawal of the morphine, and 
too frequently the patient passes from opium to the cocaine, and finally 
to the alcohol habit, all of which are equally bad. 

A method of treatment of the morphine habit which has attained 
considerable popularity is the so-called Towns' method. This method 
is also utilized in the treatment of patients addicted to cocaine and 
alcohol. It appears exceedingly rigorous, but it is claimed that even 
debilitated and feeble patients are able to withstand it with advan- 
tage. The patient, being under absolute control as to his ability to 
obtain morphine, is given five compound cathartic pills and in addi- 
tion five grains of blue mass. Six hours later, if these have not acted, 
a saline purge is given. After the patient has three or four copious 
movements he receives, by the mouth or by hypodermic injection, 
according to his custom in taking the drug, two-thirds to three- 
fourths of his total daily intake in three divided doses at half-hour 
intervals. Six drops of a mixture of tincture of belladonna, 2 parts; 
fluidextract of xanthoxylin, 1 part; and nuidextract of hyoscyamus, 
1 part, are given in a capsule at the same time as the morphine, cocaine, 
or alcohol and repeated every hour for six hours. At the end of six 
hours, the dose of this mixture is increased by 2 drops and it is continued 
every subsequent hour, day and night continuously, throughout 
the treatment, increasing by 2 drops every six hours until 16 drops 
are given at a dose. If the patient shows very marked symptoms 
of the physiological action of the belladonna mixture the dose may 
be diminished, but, on the other hand, if he is resistant to the drug, 
it must be increased up to 20 drops every hour. Ten hours after 
the first dose of morphine has been received the patient is again given 
5 compound cathartic pills and 5 grains of blue mass and if these 
doses do not act upon the bowels in six or eight hours a vigorous saline 
purge is administered. The morphine is used after this purgation in 
half the original dose, and ten hours later the same number of com- 
pound cathartic pills and the same amount of blue mass is used. 
After thirty-six hours have elapsed from the beginning of the treat- 
ment the third dose of morphine, which is one-fourth of the original 
amount, is given, and it is claimed that this is usually the last dose 
which is needful. Forty-six hours after the beginning of the treat- 
ment the compound cathartic pills and blue mass are again given, 
again followed by a saline, and, possibly, as late as the fifty-sixth hour 
of treatment a fourth small dose of morphine may be used with two 
ounces of castor oil. 

When alcoholism is being treated, the belladonna mixture and the 
5 compound cathartic pills and 5 grains of blue mass are given simul- 
taneously at the first dose and then repeated on the twelfth, twenty- 
fourth, and thirty-sixth hour, and castor oil is given after the forty- 



412 • DRUGS. 

fourth hour. In cases where nervous excitement is very marked, a 
continuous hot bath is to be used as a sedative method of treatment. 
After this plan has been carried out the patient is given tonics, fresh 
air, moderate exercise and good surroundings. 

Therapeutics. — Opium is used for the relief of five great conditions, 
which will be spoken of seriatim, the minor uses of the drug being 
considered afterward. These are pain, insomnia, inflammation and 
irritation, oversecretion, and systemic strain. 

Pain. — Opium is the best remedy that we possess for the relief of 
all forms of pain, except in those instances when neuralgia is present, 
when antipyrine and its fellow-compounds exceed it in medicinal value 
because they have no marked after-effects. It is to be remembered, 
however, that no drug has yet been discovered which equals its pain- 
relieving power in this or any other painful affection. In one form of 
pain opium is not to be employed — namely, that arising from cerebral 
congestion and cerebritis, for it is distinctly contraindicated in these 
affections, as it aggravates them. In acute or traumatic meningitis, 
however, opium is of great service, either alone or combined with 
mercury in sthenic cases. In the treatment of renal and hepatic 
colic associated with spasm, and in dysmenorrhea, belladonna, 
and opium given together will relieve the spasm and pain, and 
yet so counteract each other elsewhere in the body as to be devoid of 
marked effect upon other organs. Usually in these severely painful 
affections it is best to give morphine and atropine hypodermieally. 
Persons suffering from severe pain will usually bear larger amounts of 
opium than individuals without pain. 

For the relief of violent pain physicians of experience usually employ 
morphine hypodermieally as the most rapid and effective means of 
giving relief. If this is not possible, the morphine should be given 
by the mouth in a little hot water with or without whisky or brandy 
added to it; or tincture of deodorized opium may be given in the same 
manner. If neither the hypodermic needle nor the draught can be 
resorted to, then the drug is best given, in the form of the tincture, by 
the rectum, being first mixed with warm starch-water. If the pain is 
chiefly in the pelvic viscera, the rectal administration of the drug is 
advisable by clyster or by suppository. 

When pain is due to violent sciatica or to muscular spasm, it is 
best relieved by injecting the morphine directly into the subcutaneous 
tissues or the muscles of the affected part. In other instances local 
pain due to superficial inflammation may be relieved by compresses 
wet with laudanum and lead-water. 

To patients who are prone to frequent attacks of pain opium must be 
given with the greatest caution, as the ' 'opium habit" is easily produced. 

Many surgeons are in the habit of giving J to J grain (0.008-0.015) 
hypodermieally before administering ether or chloroform, for the pro- 
duction of surgical anaesthesia, because less of the latter drugs are 
needed to cause anaesthesia. 



OPIUM. ' 413 

(For the use of morphine and scopolamine for the production of 
surgical anesthesia, see Scopolamine.) 

Insomnia. — Opium, while incapable of producing sleep in almost 
every case in which it is given, save in those individuals who by reason 
of idiosyncrasy are made wakeful by it, is only to be used in those 
instances where the sleeplessness is due to pain. If constantly used 
for the relief of insomnia or pain, the opium habit is rapidly contracted, 
and for this reason the use of this drug should be alternated with 
chloral, cannabis indica, and other soporific drugs. 

In some cases chloral and morphine, when given in small doses in 
combination, will so act upon the brain as to produce sleep. Thus, 
in the following prescription, the dose of both active ingredients is 
much smaller than would be needed if either was used alone, yet the 
result sought by their use — namely, sleep — is readily produced: 

1^ — Morphina? sulphatis gr. ij (0.12). 

Chlorali hydrati 5j (4.0). 

Syrupi fgj (30.0). 

Aquse destillatse fgij (60.0).— M. 

S. — Dessertspoonful (8.0) at 9 p.m., and, if needed, again at 10 or 11 o'clock. 

In the persistent insomnia of typhoid fever, croupous pneumonia, 
and all acute diseases in which nervous exhaustion is due to lack of 
sleep, a hypodermic injection of morphine will sometimes produce most 
excellent results, but the proper use of cold bathing in typhoid fever 
is to be preferred for this purpose if it can be employed. (See Cold, 
Part III.) 

Inflammation and Irritation. — Opium seems to possess some 
influence over inflammation which we cannot explain, and both small 
and large doses are valuable in inflammation of serous membranes, 
such as pleuritis, meningitis, and pericarditis. In peritonitis opium 
has been thought to be useful, but grave doubts are now entertained 
as to its value. (See the article on Peritonitis in Part IV.) 

Opium allays the nervous excitement and cough following haemop- 
tysis, and the intense unrest caused by itching skin diseases, as, for 
example, the irritation of smallpox. 

Sometimes intense irritation or inflammation produces so great an 
effect upon unstriped muscular fibres as to cause spasm or paralysis, as 
in retention of urine, cystitis, or the constipation following inflamma- 
tion of the bowels due to the ingestion of irritating foods; under these 
circumstances the employment of opium is indicated, and is usually 
very successful. In irritative coughs morphine given in syrup of wild- 
cherry bark does good in the dose of yV to ^o grain (0.005-0.006). 

In some cases of irritable cough due to a tickling sensation in the 
larynx, much relief can be had by inhaling the steam arising from a 
cup of boiling water in which has been placed a drachm or two of 
paregoric. 

Whenever cough is excessive — that is, greater than is necessary to 
free the lungs from mucus — morphine may be given in small doses, k If 



414 DRUGS. 

the lungs contain more rales after its use than before, its use must be 
stopped, as the increase in the number of rales indicates an increased 
accumulation of mucus. 

In the treatment of strangury due to cystitis, and in rectal inflam- 
mation, provided they are not acute, and after operation on the pelvic 
organs, suppositories of the strength of | to \ grain (0.015-0.03) 
of the watery extract of opium are useful. In excessive vomiting 
from any cause, except it be from a previous dose of opium, an enema 
of tincture of deodorized opium 30 minims (2.0) and starch-water 4 
ounces (120.0), with 40 grains (2.6) of bromide of sodium, will be 
found of value. (See Vomiting, Part IV.) 

In muscular rheumatism and similar states, and in the incipient 
stage of a "cold," opium in the form of Dover's powder in the dose 
of 5 to 10 grains (0.30-0.60) will often produce a cure, particularly 
if employed in combination with hot drinks and a hot foot-bath. 
Camphor can often be added to the Dover's powder with advantage. 
(See Coryza, Part IV.) 

For sprains and bruises lead-water and laudanum is one of the best 
applications. (See article on Lead.) If the skin is broken, the laud- 
anum may be used alone to relieve pain, and, by its alcohol, will act 
as an antiseptic. Opium is also a useful drug in the treatment of inter- 
nal and external burns to relieve the pain and irritation. 

Oversecretion. — In serous diarrhea, diabetes insipidus and mel- 
litus, and in the treatment of oversecretion on the part of all secreting 
surfaces except the skin, opium may be used. 

Opium is said to decrease the amount of urine before decreasing the 
amount of the sugar in diabetes. However this may be, the employ- 
ment of opium or morphine or codeine in diabetes is a valuable form 
of treatment. When moderate doses fail their size must be rapidly 
increased, as the effect may be obtained only by ascending amounts, 
and diabetic patients seem peculiarly immune to the nervous influence 
of this drug and its alkaloids. Morphine is, therapeutically, more 
powerful than codeine, but crude opium is more powerful for good in 
this affection than either. None of therm probably,, cure the disease, 
but so modify it as to make life bearable ; for the sugar is decreased 
in many cases, and the excessive hunger, thirst, and nervous irri- 
tability are relieved. Itching of the skin is also allayed in this class 
of patients by its use. (See article on Diabetes, Part IV.) The sud- 
den withdrawal of opium from a case of diabetes may precipitate 
diabetic coma. 

Opium should not be used to arrest an attack of mucous diarrh&a 
until after the mucus which is already present in the bowel has been 
swept out of the intestinal canal by a dose of castor oil or magne- 
sium sulphate. Minute doses of -^ to j-q grain (0.0008 to 0.0012) of 
morphine given hypodermically will sometimes check summer diarrh&a 
in children at once after all undigested food has been swept out by 
castor oil. (See article on Diarrhoea.) 



OPIUM. 415 

Morphine rather than opium is used to relieve pain because it does 
not cause so much constipation, but opium is better to check diarrhoea. 
Paregoric is particularly useful in diarrhoea because it contains a 
volatile oil and camphor. 

Systemic Strain. — In prolonged strain upon the system, as in 
great physical or nervous effort, or more frequently in old age to smooth 
the remaining years of life and decrease worry, opium is useful, but 
its use in young persons is most dangerous, as it is almost certain to 
produce the opium habit. In asthenic fevers opium is thought to be 
supportive, but its use is apt to cause so many other conditions, such 
as constipation, anorexia, or mental depression, that alcohol is much 
better for this purpose. In advanced phthisis it is often justifiable to 
give sufficient opium to keep the patient free from pain and discomfort 
for the remaining hours of his life ; but care must be taken that the 
dose does not interfere with the breathing and so hasten death, 

In heart disease, particularly of the mitral valves, the patient can 
often breathe easily only when awake, starting up when he falls asleep 
and gasping for breath. It is stated by some writers that morphine 
will relieve this state and permit sleep, but that it will not be of service 
in aortic disease. While this may be partly true, the drug will often 
give great relief in all forms of cardiac dyspnoea, and ought always 
to be tried with caution, although it is contraindicated if the heart 
has undergone fatty degeneration. Care should be taken that the 
first dose is small, as in some instances it increases the discomfort. 
The relief obtained is supposed to be due to cardiac stimulation by 
the drug, and this is no doubt correct, since the other cardiac stimu- 
lants, such as digitalis, will often fail when morphine succeeds. The 
presence of cyanosis and lividity is said to be no contraindication 
to the hypodermic use of morphine under these circumstances, pro- 
vided the dose is not unreasonably large, and provided these signs 
are purely circulatory in origin. If they are due to pulmonary 
oedema or diffuse bronchitis, it is unsafe. Not rarely in the course 
of pneumonia and typhoid fever a state of nervous restlessness with 
active talkative delirium develops, in which the patient may die from 
lack of sleep. At such times a hypodermic dose of morphine may be 
most useful and save life. The drug should be given hypodermically 
for these purposes in the dose of about J grain (0.015). 

Opium and morphine, particularly the latter, have been freely 
given to produce quiet in patients with uremic conmdsions. The 
practice is a dangerous one, and should not be resorted to as a rule, as 
the impaired state of the kidneys prevents elimination of the drug. 

Administration. — Recent studies upon the action of opium and its 
alkaloids show that it acts in an inhibitory manner upon gastric diges- 
tion and absorption, decreasing the amount of hydrochloric acid in 
the gastric juice. For this reason, unless there is an excess of acid 
present in the stomach, it is well not to give opium or morphine at 
meal-time, but some time after. 



416 DRUGS. 

Opium itself is used in the form of the powder (Opii Pulvis, U. S.), 
and in granulated form (Opium Granulation, U. S.) in the dose of from 
i to 2 grains (0.015-0.12) and deodorized opium (Opium Deodoratum, 
U. S.), which is deprived of its narcotine, dose J to 2 grains (0.03-0.12). 
Both these preparations should yield on assay not less than 12 per 
cent, nor more than 12.5 per cent, of morphine. Of the watery extract 
(Extractum Opii, U. S. and Extractum Opii Siccum, B. P.) the dose is 
i to | grain (0.015-0.03), i to 1 grain (0.015-0.06), B. P. Of the liquid 
preparations we have paregoric (Tinctura Opii Camphorata, U. S.; 
Tinctura Camphoroe Composita, B. P.), dose 1 drachm to 1 tablespoon- 
ful (4.0-16.0); B. P. dose is 30 to 60 minims (2.0-4.0); laudanum 
(Tinctura Opii, U. S ; and B. P.), dose 5 to 20 minims (0.30-1.30), 
containing not less than 1.2 nor more than 1.25 Gm. (B. P. 1 per cent.) 
of crystallizable morphine in 100 mils.; the tincture of deodorized 
opium (Tinctura Opii Deodorati, U. S.), dose 5 to 20 minims (0.30- 
1.30), containing not less than 1.2 nor more than 1.25 Gm. of crystal- 
lizable morphine in 100 mils.; Vinum Opii, sometimes called Syden- 
ham's laudanum, dose 5 to 20 minims (0.30-1.30); and Acetum Opii, 
or black drop, dose 5 to 20 minims (0.30-1.30). 

As all the liquid preparations of opium in the U. S. P. are of 10 
per cent, strength, except paregoric, which is about 2 grains to the 
ounce, the dose of all of them except paregoric is identical. This is 
a fact to be particularly remembered by students. 

Under the name of Dover's powder (Pulvis Ipecacuanha et Opii, 
U. S.; Pulvis Ipecacuanha Compositus, B. P.), a powder containing 
1 part of powdered opium, 1 part of powdered ipecac, and 8 parts of 
sugar of milk is largely used. The dose is 5 to 20 grains (0.30-1.30). 
It is more efficacious if separated into fifths and taken in divided doses. 
The tincture of ipecac and opium (Tinctura Ipecacuanha et Opii) is 
given in the dose of 5 to 20 minims (0.30-1.30). 

The preparations of opium official in the B. P., other than those 
named, are Extractum Opii Liquidum, dose 5 to 30 minims (0.3-2.0) ; 
Pulvis Opii Compositus, composed of opium, pepper, ginger, caraway- 
fruit, and tragacanth, dose 2 to 10 grains (0.12-0.60); Tinctura Opii 
Ammoniata, dose \ to 1 drachm (2.0-4.0). Pilula Saponis Composita, 
B. P., is really a preparation of opium. It is sometimes necessary 
to give this drug to patients without their knowledge, and it may be 
prescribed in this way, the patient not learning from the prescription 
the nature of the medicine. The dose is 2 to 4 grains (0.12-0.25). 

Under the name of pantopon (Pantopium Hydrochloridum) a German 
preparation, a soluble preparation of the combined alkaloids of opium 
is on the market for use by the mouth or hypodermic needle. It is 
claimed to be more sedative than morphine. The dose is \ to \ grain 
(0.01-0.015). 

Untoward Effects. — When opium is given to some individuals it pro- 
duces for several hours marked wakefulness followed by sleep, and 
in many patients causes after its primary influence great nausea, and 



OPIUM. 417 

sometimes vomiting. The mental depression may be simply over- 
whelming, and the very fact of having to drag out existence is a curse. 
By far the most effective mode of preventing these very distressing 
effects of opium or its derivatives is to administer with this drug about 
y^q grain of nitroglycerin. One of the chief causes, however, of the 
nausea produced by the use of opium or morphine is the change in the 
body of morphine into oxy-dimorphine, which is eliminated into the 
stomach and there reabsorbed, and then induces these secondary effects. 
It is also a fact that these symptoms can be largely relieved by the 
use of 20 grains (1.3) of bromide of potassium, which must be taken 
at the same time as the opiate, and by employing the preparations of 
opium largely devoid of narcotine, such as the deodorized tincture or 
deodorized opium itself. Whenever possible these preparations should 
be used to the exclusion of the others. Haig is responsible for the 
assertion that, as opium frees the blood from uric acid by causing its 
retention in the tissues of the body, the pleasant effects are so produced, 
and that, the retention being cumulative, no sooner does the effect of 
the opiate pass off than the uric acid is set free in the blood, and as a 
result depression ensues. He states that if salicylates are given with 
the opium retention does not occur, and the unpleasant sequelae are 
modified or prevented. After the untoward symptoms come on coffee and 
stimulants may be used with advantage to overcome them. In some 
persons the use of opium is followed by itching of the skin or by the 
development of an erythematous rash which may go on to desquamation. 

Children bear opium badly, and some children are very much more 
susceptible than others to its influence. 

One-eighth grain of morphine has caused death in an adult when 
given hypodermically, probably because it entered a vein. Sometimes 
the drug causes collapse, or in other cases an eruption upon the skin 
of the body. 

The use of repeated doses of morphine for several days often excites 
obstinate vomiting, due probably to the change of the drug into oxy- 
dimorphine or apomorphine. 

Codeine, 

(See p. 232.) 

Morphine. 

Morphina, IT. S. and B. P., is the chief alkaloid of opium, but 
owing to its insolubility is rarely used, being generally given in the 
form of sulphate. 

Sulphate of morphine (Morphines Sulphas, IT. S.) is given in the 
dose of | to J grain (0.008-0.03), either by the mouth or hypoder- 
mically. Besides the sulphate of morphine we have the hydrochloride 
(Morphines Hydrochloridum, IT. S. and B. P.), and the tartrate (Mor- 
phine Tartras, B. P.), all given in the dose of f to f grain (0.008-0.03). 
27 



418 DRUGS. 

In the U. S. Pharmacopoeia of 1870 a solution of morphine was official, 
called Liquor Morphince Sulphatis (B. P.), dose 1 to 2 drachms (4.0- 
8.0) ; but it is no longer official and should not be called for. Magen- 
die's solution of morphine is sixteen times as strong as the liquor just 
named (16 grains to the ounce), and is also not official. The words 
"Liquor Morphinse Sulphatis" may cause Magendie's solution to be 
dispensed particularly in New York State, and care should be taken 
that poisoning does not result. Pubis Morphince Compositus, or 
Tully's powder, is given in the dose of 10 grains (0.60). Ten grains 
contain sulphate of morphine about J grain (0.6), camphor 3 grains 
(0.19), liquorice 3 J grains (0.20), and precipitated calcium carbonate 
3 J grains (0.20). It is used to check forming colds and as a nervous 
sedative. Troches of morphine and ipecac (Trochisci Morphince et 
Ipecacuanha) are given one or two at a time for irritation of the pharynx. 

The following additional preparations of morphine are official in the 
B. P. : Liquor Morphince Hydrochloridi and Liquor Morphince Tartratis, 
dose 10 to 60 minims (0.60-4.0); Tinctura Chloroformi et Morphince 
Composita, dose 5 to 15 minims (0.30-1.0); Suppositoria Morphince, 
each suppository containing J grain (0.015) of morphine; Trochiscus 
Morphince and Trochiscus Morphince et Ipecacuanhas, each lozenge 
containing -£$■ grain (0.002) of morphine, dose 1 to 4. Liquor Mor- 
phince Acetatis is given in 10- to 60-minim (0.6-4.0) doses. Injectio 
Morpjiince Hypodermica, B. P., contains J grain (0.03) of the tartrate 
of morphine in each 22 minims (1.4) of water. Its dose is 1 to 10 
minims (0.05-0.6). 

Incompatibles. — Morphine is incompatible with potassium perman- 
ganate and with tannic or gallic acid or solutions containing them; 
with alkalies, such as potassium, sodium, and ammonium salts, but 
with the chloride of ammonium it is not incompatible. With tincture 
of chloride of iron it forms a deep red color (meconic acid). 

ORTHOFORM. 

Orthoform, which is the methyl ester of para-aminometaoxybenzoic 
acid, has been supplanted by "orthoform new," which is metamino- 
para-oxybenzoic acid and the latter is a colorless, bulky, odorless, and 
tasteless powder which is quite soluble in hot water. It is used as 
a local anaesthetic and antiseptic dressing for small wounds and burns, 
and is said to be non-toxic, but this is an error. It may be applied 
in powder or ointment. The latter is usually of the strength of 2 
drachms to the ounce of lanolin (8.0-30.0). . It may be given by the 
stomach in cases of epigastric pain to determine its source. In cases 
of gastric ulcer it may relieve the pain, but if the pain be due to gall- 
stones it will fail. The dose is 2 to 5 grains (0.12-0.3), in pill or 
capsule, three times a day on an empty stomach. 



OXYGEN. 419 

OVARIAN EXTRACT. 

The ovarian gland, in the form of the dried gland substance or 
in that of an extract made from it, has been used for relief of the 
nervous and nutritional disturbances of the menopause, whether they 
be the result of age or of operative removal of these bodies, It is said 
to be the most efficacious in those instances in which the ovaries have 
been removed from young women. As the use of the ovarian extract 
in medicinal doses seems to be harmless, it may be given for a long 
time without danger. The beginning dose should be 2 to 4 grains 
(0.12-0.25) a day, and this be gradually increased until some effect 
is produced or it proves useless. The best method of giving it is in 
compressed tablet or in capsule. Professional opinion as to its value 
is not favorable. (See Corpus Luteum.) 

OX-GALL. 

Ox-gall (Extractum Felis Boms, U. S.) is, as its name implies, dried 
ox-bile, derived from the gall-bladder of the common ox (Bos taurus). 
It is used in medicine for the purpose of relieving certain forms of 
indigestion which result from deficient secretion of bile or which 
occur in persons who digest fats with difficulty. In full doses it is 
apt to cause some looseness of the bowels, and it may be given with 
the object of producing this condition. When it is used, the fact should 
be remembered that bile prevents the gastric juice from acting upon 
proteid or albuminous substances, shrivelling them up, and in addition 
so alters the gastric liquids as to decrease their digestive power. We 
know, therefore, that this drug must be administered some hours 
after meals, as a rule, or, in other words, when gastric digestion is 
ended and intestinal activity is beginning. The dose of ox-gall is 5 
to 15 grains (0.30-1.0). Purified ox-gall; Fel Bovinum Purificatum, 
B. P.) is given in the same dose as U. S. P. preparation. 

OXYGEN. 

The gas oxygen is now widely used in medical and surgical practice 
in two ways, as follows: By inhalation of the gas itself from a cylin- 
der in which it is compressed until 40 gallons occupy a very small 
space; and by the use of the dioxide or peroxide of hydrogen, which 
is applied locally to diseased surfaces. (See Hydrogen Peroxide.) 

Inhalations of oxygen are useful in the second and third stages 
of pneumonia where the patient seems to be suffering from deficient 
aeration of the blood and associated heart-distention. They are also of 
value in advanced bronchitis, particularly that of old persons, and for the 
resuscitation of individuals asphyxiated by coal-gas (Hare and Martin). 
In phthisis and other exhausting diseases oxygen will allay dyspnoea 
and oppression. Oxygen inhalations are also of service in the treat- 
ment of anaemia in all its forms and give relief even in pernicious 



420 DRUGS. 

anoemia and in leukcemia. Often a mixture of oxygen gas 60 parts 
and nitrous oxide gas 40 parts is used as a stimulant inhalation and 
nervous sedative. 

The clinical results which have so far been obtained from the admin- 
istration of ether and chloroform vapor when combined with oxygen 
gas seem to prove beyond all doubt that the oxygen decreases the 
danger of the anaesthetic and to a large extent obviates the difficulties 
which attend the administration of these drugs, and most of the 
untoward effects which result from their use. Thus, when oxygen 
is given with ether, vomiting is less frequently met with, excessive 
pallor is rarely seen, and post-operative depression seems to be largely 
avoided. 

As a general rule, however, it has been the custom of physicians 
and surgeons who have employed oxygen gas in combination with ether 
or chloroform, to place the anaesthetic in a wash-bottle and then to 
allow the oxygen gas to pass through it in such a way that the patient 
received in the inhaler a mixture of anaesthetic vapor and oxygen, the 
mixture resulting from the passage of the oxygen gas through the 
liquid anaesthetic in the bottle. An evident disadvantage of this 
arrangement is that the quantity of anaesthetic which is volatilized 
can only be in direct proportion to the volume of oxygen gas which is 
forced through the wash-bottle, and therefore with every increase in the 
quantity of vapor which the patient receives he must also receive an 
increased quantity of oxygen. It has been claimed, too, by those who 
have employed the ether and oxygen combination most frequently, that 
in a large proportion of cases a greater length of time is required 
for the anaesthetizing of the patient, and that in some cases it seems 
almost impossible to get the patient under the direct influence of the 
drug. This difficulty lies in the fact that as soon as a large quantity of 
oxygen gas is used to convey much of the anaesthetic vapor to the 
lungs, the patient rapidly passes into a condition which is called by 
physiologists apnoea. The respiratory centre is no longer irritated by 
the normal proportions of carbonic acid in the blood, and therefore 
sends out feeble respiratory impulses; and as the patient does not 
breathe so rapidly or so deeply as before, the result is that very small 
quantities of the anaesthetic are taken into the body. 

The tube which leads off from the oxygen tank should be placed 
under the edge of the inhaler and the gas given as desired. 

The writer cannot condemn too strongly the method of employing 
chloroform vapor and oxygen by passing the oxygen directly through 
the chloroform without the free administration of air in addition, for, 
after all, air is what we are intended to breathe, and not oxygen gas 
alone, although it may be advantageous at times to add an increased 
quantity of oxygen to the air. 

Still more severe condemnation should be directed toward the attach- 
ment which is placed on some of the Junker inhalers, and which con- 
sists of a small rubber bag which, instead of acting as a reservoir of 



PANCREATIN AND PANCREATIC EXTRACTS. 421 

fresh anesthetic vapor and oxygen, is inflated and collapsed by the 
expiration and the inspiration of the patient, who does not receive even 
fresh oxygen and anaesthetic vapor, much less fresh air, but, on the 
contrary, inhales again and again air, oxygen, and vapor which are 
loaded with the impurities of frequent expiratory efforts. 

(For the directions for using oxygen with nitrous oxide as an anaes- 
thetic see the article on Nitrous Oxide.) 



PANCREATIN AND PANCREATIC EXTRACTS. 

Under these names a number of firms now sell an extract from the 
pancreatic gland or juice of the hog or ox and the U. S. P. recognizes 
such a product under the name of Pancreatinum. Pancreatin should 
convert 25 times its own weight of starch into substances soluble in 
water (U. S. P.). It contains, or should contain, the four pancreatic 
ferments — trypsin, which digests proteids (meat, eggs, etc.); steapsin, 
which splits up and emulsifies the fats; amylopsin, which has diastatic 
power (that is, converts starch into sugar), and finally a milk-curdling 
ferment. 

Pancreatin may be made by the physician in the following manner: 
Take the pancreas of a pig which has been killed about six hours 
after a full meal, the organ being therefore active, and, after chopping 
it finely, add to it four times its weight of dilute alcohol and allow 
it to stand for twelve hours. Decant or filter off the alcohol, and 
give the filtrate in the dose of 1 to 2 drachms (4.0-S.O). Or, better 
still, as follows: Wash and chop finely a fresh pancreas, and allow 
the gland to soak in alcohol (absolute) twenty-four to forty-eight hours. 
Then squeeze out the alcohol and add to the gland ten times its weight 
of glycerin. The mixture must stand forty-eight hours and then be 
filtered, and may be used in doses of 30 minims (2.0) to each glass of 
milk. (For the use of pancreatin in artificial digestion see the article 
on Peptonized Foods in Part III.) 

Pancreatin, as prepared for the market, is a dry powder, given in 
the dose of 2 to 20 grains (0.12-1.3) after meals or during them. 

Pancreatin should usually be prescribed with bicarbonate of sodium 
to aid it in its digestive action. It is indicated in all cases of lienteric 
diarrhoea and in many cases ^f deficient digestion. Pancreatin, or the 
powdered pancreas, may also be freely used in those cases of diabetes 
mellitus in which the disease depends upon a lesion of the pancreatic 
gland, as carcinoma or atrophy from other cause. 

Some doubt has been cast upon the usefulness of the employment 
of pancreatin in foods unless this ferment is allowed to act upon the 
aliment before it is swallowed by the patient, on the ground that 
pancreatin is destroyed and rendered inert in the presence of the acid 
which it meets in the stomach. This objection is not a valid one, 
because food remains in the stomach for from fifteen minutes to half 



422 DRUGS. 

an hour before enough gastric juice is secreted to interfere with the 
pancreatic action. It is during this preliminary period that thp work 
of the pancreatin is accomplished. 

Pancreatized or peptonized foods should not be employed unless 
really needed, nor continued for any length of time, as digestion is 
finally impaired by torpor of the glands arising from disuse. 

The B. P. recognizes a solution (Liquor Pancreatis); dose 1 to 2 
drachms (4.0-8.0). 

The dose of pancreatin is from 2 to 20 grains (0.12-h3). 

PAPAIN, PAPAYOTIN, AND PAPOID. 

Papain, papayotin, and papoid are names given to a digestive fer- 
ment derived from the juice of Carica papaya. This ferment pos- 
sesses the power of changing proteids into peptones in the presence 
of an acid or an alkali, or even in a neutral mixture, thereby differing 
from pepsin and pancreatin. This power would be of great value, 
since the drug would then be useful in all forms of dyspepsia, were it 
not that careful experimentation renders it doubtful whether papain, 
papayotin, or papoid can really supplant either of the animal fer- 
ments named above. The dose of all these products is from 1 to 
8 grains (0.06-0.50) given in solution, or better in pill. The plant 
itself, taken internally, has the reputation of being capable of causing 
abortion. 

PARALDEHYDE. 

Paraldehydum, U. S. and B. P., is a form of aldehyde used as a 
soporific and nervous sedative, and is a clear, colorless liquid with an 
ethereal odor and a burning, followed by a cool, taste. It should be 
kept in dark, well-stoppered bottles in a cool place. Paraldehyde is 
readily soluble in alcohol, moderately so in cold water, less so in hot 
water. It possesses the great disadvantages of being necessarily given 
in large dose and of having a disagreeable taste and odor. It is also 
prone to disorder the stomach. Paraldehyde kills by respiratory 
failure when taken in overdose, but is not so depressant to the heart 
as is chloral, and it is not to be classed as a dangerous drug. Clouster 
records a case which received 2 ounces (60.0) by accident without grave 
results. The drug soon loses its power as a soporific. As it is speedily 
absorbed and acts promptly, it ought to be taken after the patient is in 
bed. The dose is 20 minims to 1 drachm (1 .3-4.0) in capsule, or, better 
still, it may be used, after the formula of Yvon, as follows: 

3— Paraldehydi ......... Si'ss (10.0). 

Alcoholis (90 per cent.) f§iss (45.0), 

Tinctura? vanillse f 5ss (2.0). 

Aqua- destillatse f §j (30.0). 

Syrupi q. s. ad fgiv (120.0).— M. 

S. — A dessertspoonful (8.0) every half-hour until sleep is obtained. 



PEPPER. 423 

Another formula is as follows: 

3— Paraldehyde . 5ij (8.0). 

Olei amygdalae amarse (sine acid, hydrocyanic.) . Tfliij (0.2). 

Syrupi f5J (30.0). 

Fluidextracti glycyrrhizee f3ij (8.0). 

Aquae destillatae q. s. ad f5iv (120.0).— M. 

S # — Half to one drachm (2.0-4.0) a a dose. 

PARATHYROID GLAND. 

Parathyroid gland is used to relieve symptoms induced by the 
removal or damage of the patient's glands in thyroidectomy and for 
the relief of tetany, paralysis agitans, eclampsia and chorea. It is 
marketed in tablets containing one-tenth of a grain equal to three- 
fifths of a grain of fresh gland. The dose is usually one or two tablets 
a day. 



PAREIRA. 

Pareira (Pareim Radix, B. P.) is the root of Chondodendron tomen- 
tosum, a plant of Peru and Brazil, and is used as a diuretic of 
an alterative or stimulant character and for the relief of chronic 
inflammations of the genito-urinary tract in general, such as pyelitis, 
cystitis of a subacute type, and similar pathological states. The dose 
of the unofficial infusion is a wineglassful (30.0), and the fluidextract 
(Fluidextractum Pareirce) is given in the dose of a teaspoonful (4.0) 
three times a day. The B. P. preparation of this drug is Extractum 
Pareirce Liquidum, dose 1 to 2 drachms (4.0-8.0). 

PEPO. 

Pepo (Cucurbita pepo), U. S., pumpkin-seed, the seed of the ordinary 
domestic pumpkin, is a useful and efficient vermifuge for the tape- 
worm. The seeds are not only efficient, but are harmless to the host 
of the worm. The outer coverings of the seeds should be removed, 
and the remaining part rubbed up into an emulsion with water or into 
an electuary with sugar, the dose of the seed being 2 ounces (60.0). 
This mass should be taken on an empty stomach, and followed in 
from one to two hours by an active purge. 



PEPPER. 

Piper, U. S., or black pepper (Piper Nigrum, B. P.), is the unripe 
fruit of Piper nigrum, a vine of India, Java, Borneo, and Siam. It 
contains a basic principle, piperine, which is official. 



424 DRUGS. 

Therapeutics. — Black pepper may be used externally as a counter- 
irritant or internally as a carminative and stimulant to the alimentary 
canal. It may also be used in all cases of atony of the mucous mem- 
branes of the genito-urinary system, but is contraindicated whenever 
acute inflammation is present, as in acute gonorrhoea. It may be 
used with marked relief in the treatment of intestinal flatulence. 

The oleoresin of pepper (Oleoresina Piperis, U. S.) is given in the 
dose of J to 2 minims (0.015-0.12) in laxative pills, to prevent griping. 

A confection (Confectio Piperis) is official in the B. P., given in the 
dose of 1 to 2 drachms (4.0-8.0). 



PEPPERMINT. 

Mentha Piperita, U. S., is official in the form of the dried leaves and 
tops of Mentha piperita. It has an aromatic odor and taste and con- 
tains an oil. Locally applied, the oil acts as an irritant and local anaes- 
thetic. From this oil is obtained menthol, a camphoraceous substance 
of a hot, burning taste, possessing marked power as a local anaesthetic. 
(See Menthol, below.) 

Therapeutics. — Peppermint is used very largely as a domestic remedy 
for flatulence and infantile colic. Sometimes the oil is added to pur- 
gative pills to prevent griping, and it may be employed to disguise 
the taste of any medicines which are disagreeable to take. In this 
respect it is used as are all the volatile oils. In the colic of children of 
six months to a year of age, when it is unusually severe and associated 
with nervous symptoms, the following will be found of value: 

^ — Chlorali hydrati gr. xvj (1.0). 

Potassii bromidi gr. xxxij (2.0). 

Aquae menthse piperita? f §ij (60.0). — M. 

S. — Teaspoonful (4.0) in a little warm water every four hours. 

When used in the treatment of neuralgia, oil of peppermint should 
be placed on a piece of linen or muslin rag and applied over the affected 
spot. Care must be taken that it does not blister the skin. If, after 
its removal, the burning is too severe to be borne, a little cosmoline 
or olive oil should be applied. Oil of peppermint is sometimes placed 
on cotton and inserted into dental cavities for toothache. 

It is to be remembered that the more menthol is present in the oil 
the more active will it be as an anaesthetic, and that the Chinese oil 
contains more menthol than the American oil. 

Administration. — Peppermint is used in the form of the oil (Oleum 
Menthce Piperita, U. S. and B. P.), dose 1 to 4 minims (0.06-0.25); 
the spirit (Spiritus Mentha? Piperita, U. S. and B. P.), dose 10 to 
30 minims (0.60-2.0); the water (Aqua Mentha Piperita, U. S. and 
B. P.), dose 1 to 2 drachms (4.0-8.0); and, finally, as the troches 
(Trochisci Mentha Piperita), to be held in the mouth in indefinite 
number. 



PEPPERMINT. 



425 



Fig. 



Menthol. 

Menthol, U. S. and B. P., or mint stearopten, or, 
mint camphor, is derived chiefly from the essential 
mint. It occurs in colorless prismatic 
crystals with a strong odor of pep- 
permint. Upon it rests much, if not 
all, of the therapeutic activity of pep- 
permint. Menthol is slightly soluble 
in water, very soluble in alcohol, 
ether, and in oils. 

Menthol has been used in the 
vomiting of pregnancy with great 
advantage in hourly doses of a tea- 
spoonful of the following: 



as it 
oil of 



is called, 
pepper- 



^ — Mentholis . . 
Spiritus frumenti 
Sj^rupi . 



gr.xv(l.O). 

f ovj (24.0). 
fSj (30.0). 




Nebulizer. The small pump on the right 
side forces air through the black tube in the 
glass jar. This air escapes from an aper- 
ture in the side of the tube and draws up 
the medicated liquid, which is then driven 
forcibly against the side of the glass. The 
finely comminuted fluid then 
vapor through the exit tube. 



Menthol has also been used as a 
carminative and in gastralgia in the 
dose of from 1 to 2 grains (0.06-0.12) 
three times a day in pill or in alco- 
holic solution. It is contraindicated 
in acute inflammation of the gastric 
mucous membrane. As menthol exer- 
cises a local anaesthetic effect on the 
skin as well as on mucous membranes, 
it is used externally over the course 
of neuralgic nerves and for migraine by means of menthol pencils 

Menthol when applied to the mucous membrane of the throat o T 
nose causes a contraction of the local bloodvessels, which is not 
followed by the excessive dilatation produced by cocaine. In acute 
coryza its local application to the mucous membrane by a spray or 
dropper is often a source of great relief in a solution of about 1 grain 
(0.06) to the ounce (30.0) of water, or 3 grains (0.20) of menthol in 
J ounce (16.0) of albolene. (See Coryza, Part IV.) 

Another very useful method of applying menthol is by means of a 
simple inhaler consisting of a small glass tube of about one-quarter of 
an inch in diameter and two and a half inches in length. Both ends 
are closed by a piece of gauze and two perforated corks, the menthol 
being placed in between. The air is now drawn through this tube, and, 
being heavily loaded with the fumes, clears the nares and relieves the 
stuffiness. It is not to be only smelled, but also inhaled. Care should 
be taken that the crystals are not allowed to enter the nostrils, as they 
are almost cauterant in power. Sometimes, where great excoriation 
of the alse of the nose exists, the too persistent use of the menthol 



426 DRUGS. 

may produce small herpetic spots about the nostrils. When menthol 
is inhaled for a long time or swallowed in any quantity it is apt to 
produce severe congestive headache. 

Still another method is by the use of a nebulizer. (See Fig. 63 ; also 
article on Inhalations, Part III.) The following mixture is placed in 
the glass jar, and the air being driven through the tube a vapor of the 
drugs is given off which is a valuable sedative to the entire respiratory 
tract. 



1^ — Chloretone 
Mentholis 
Camphorse . 
Olei cinnamomi 
Petrolati liquidi 



gr. ij (0.12). 
gr. xx (1.3). 
gr. xx (1.3). 
"W (0.10). 
f§j (30.0).— M. 



S. — Use in a vaporizer every three hours for a period of about ten minutes 

Sometimes menthol in 10 per cent, alcoholic solution is dropped on 
the cone with which ether is given, to diminish the irritation caused 
by that drug when it is inhaled. 

Menthol vapor is also useful in spasmodic croup. (See Part IV.) 
Emplastrum Menthol, B. P., is used as a mild local irritant and 
anaesthetic. 

PEPSIN. 

Pepsinum, U. S. and B. P., is the digestive ferment of the gastric 
juice. That sold in the shops is generally derived from the pio-, 
and is prepared by manufacturers in many ways. Much of the 
pepsin of the market contains more peptone than pepsin, and much 
mucus and albumin. Used with hydrochloric acid in weak solution, 
pepsin carries out the digestive action of the stomach. Pepsin 
containing peptone has the peculiar musty smell of peptone, and if 
the peptone is in excess will absorb moisture and become sticky on 
exposure to the air. 

According to the U. S. P. official pepsin must have the power to 
digest three thousand times its weight of albumin. 

Therapeutics — Pepsin is a much over-rated remedy for indigestion, 
which in many cases is due to hepatic disorder or to actual disease of 
the stomach which it cannot relieve. Pancreatin will nearly always 
be found more serviceable, and should be given either during or one 
or two hours after meals. Pepsin should be used immediately after 
the food is taken or with it. Hydrochloric acid should always be given 
with pepsin to aid its action, and because it converts the pepsinogen 
in the gastric tubules into pepsin. Liquor Pepsini is given in the dose 
of 2 drachms (8.0). Pure pepsin should be given in 5- to 15-grain 
(0.30-1.0) doses. A glycerite (Glycerinum Pepsinum) is official in 
the B. P. 

Very useful and readily taken liquid preparations are pepsin essence 
and cordial, which are given in the dose of 1 to 2 drachms (4.0-8.0) 
after meals. A nutritious article of diet can be made by adding one 



PETROLATUM. 427 

teaspoonful of either of these liquids to a half-pint of warm milk, 
and allowing it to cool, thereby forming "curds and whey" through 
the action of the milk-curdling ferment. (See Part III.) 



PERMANGANATE OF POTASSIUM. 

Potassii Permanganas, U. S. and B. P., is a salt of a dark purplish- 
red color, appearing in small crystals and readily soluble in water. 
In the presence of moisture it rapidly gives up the oxygen which it 
contains and becomes the dioxide of manganese. 

By reason of its oxidizing power the permanganate of potassium 
is useful as an antiseptic and deodorant. It should not be employed 
as a disinfectant for filth, because its action is too fleeting, but in 
saturated solution, followed by oxalic acid solution, it proves itself 
one of the best disinfectants for the hands in surgical practice. (See 
Antisepsis and Disinfection.) 

Permanganate of potassium is given in the same dose for amenor- 
rhoea as the dioxide of manganese, but is much less efficacious. It 
is also very apt to irritate the stomach. 

The permanganate is thought to be useful in dyspepsia, flatulence, 
Jithwrnia, and obesity, and in the first two states is often of service, 
being a destroyer of the abnormal products by oxidation. Owing to this 
oxidizing power, it has been asserted, by Weir Mitchell and Reichert, 
to be the most efficient antidote to snake-venom if placed in the wound 
before the poison is absorbed. It should also be injected hypodermic- 
ally all about the seat of the bite. Permanganate of potassium is the 
best chemical antidote in poisoning by morphine and in that caused by 
many other vegetable alkaloids. It is also a good chemical antidote 
in phosphorus-poisoning. In large doses it is efficient in cholera. 
(See Cholera.) Owing to its rapid evolution of oxygen it acts as 
an antiseptic, and may be used to wash wounds, ulcers, and sores, 
and as a lotion in the form of a gargle or on a swab in the sore throat 
of diphtheria and scarlet fever. The solution used should be from 
2 to 6 grains (1.3-4.0) to the pint (480 mils.); the former is used on 
mucous membranes, the latter for sores and wounds. In fetid rhinitis 
and otitis media permanganate solution is useful as a wash in the pro- 
portion of 1 grain (0.06) to the ounce (30.0). When given in solution 
permanganate of potassium should be dissolved in distilled water, 
and it should never be mixed in a mortar with any organic matter, as it 
will explode. A solution (Liquor Potassii Permanganatis) is official 
in the B. P. 

PETROLATUM. 

Under the name of Petrolatum, U. S., or soft petrolatum, or Un- 
guentum Petrolei, is sold a semisolid substance derived from certain 
kinds of petroleum, and sometimes called cosmoline or vaseline. 



428 DRUGS. 

Owing to its soothing powers and non-rancidity, it is used as an 
emollient dressing in sores and skin affections. It has no value except 
as a protective. It is not absorbed, although assertions to the con- 
trary have been made. 

Petrolatum is a useful ointment base for medicaments for the skin. 
Under the name of fluid or liquid petrolatum (Petrolatum Liquidum, 
U. S.) a fluid form is sold, which is much used in the form of a spray 
in the treatment of rhinitis and after irritant applications to the nasal 
cavities. Liquid petrolatum in its heavy form is useful as a laxative 
in the dose of 1 to 2 tablespoonfuls (15.0-30.0) at night, or a table- 
spoonful (15.0) three times a day. 

Petrolatum Album (U. S.), or white petrolatum, is a purer product, 
being devoid of coloring matters. 



PHENOCOLL. 

Phenocoll is a compound closely allied to phenacetin. It is always 
used in the form of the hydrochloride of phenocoll, which occurs in a fine 
white powder, and which is soluble in water and forms a neutral solu- 
tion. It is incompatible with alkalies, and is used as an antipyretic. 

Physiological Action. — A number of studies of the action of phe- 
nocoll hydrochloride upon the animal organism have been made by 
Kobert and von Mering in Europe, and by Wood and Cerna and 
Ott in America. These investigators have found that it is different 
from most of the coal-tar antipyretics in that it has little effect on 
the red blood-corpuscles. It does not cause so great a sweat when 
the fever falls as do its near antipyretic relatives. Von Mering has 
shown that phenocoll has little lethal power, but Ott asserts that in 
poisonous dose it kills by failure of respiration, and causes paraplegia- 
cyanosis, and depression of the heart. 

Therapeutics. — As pointed out in the article on the treatment of 
Fever, antipyretic drugs are of little value as compared to bathing. 
Phenocoll may be given for the same purpose and under the same 
circumstances in the presence of fever as antipyrine or acetanilide, 
but, like these drugs, is contraindicated in advanced exhausting dis- 
eases, such as consumption. A number of clinicians have tried pheno- 
coll hydrochloride for the relief of acute rheumatism and neuralgic 
pain, with asserted success. The dose of phenocoll hydrochloride is 
5 to 8 grains (0.30-0.50) two to five times a day. It is best given in 
capsule. 

PHENOL (CARBOLIC ACID). 

Phenol, U. S., and Acidum Carbolicum, B. P., is also known as 
phenylic alcohol and phenic acid. Not only is it an acid, but in 
addition it is an alcohol of the peculiar group known as the phenols, 



PHENOL. 429 

which are derived from coal-tar by a process of distillation. Its 
acidity is, however, very feeble. The official phenol should assay 
not less than 96 per cent, of absolute phenol. 

Phenol is sold in several grades, No. 1 being the purest. Both 
Nos. 1 and 2 are crystalline, while Nos. 3, 4, 5 are impure because 
of the presence of cresylic acid and other foreign substances. Only 
No. 1 should be ordered when phenol is to be given by the mouth. 

Phenol has a characteristic odor, and varies in color according to 
its method of preparation and purity. It is soluble in 15 parts of 
water, but it is liquefied by the addition of 8 per cent, of water. 
Phenol should be kept in dark amber-colored, well-stoppered bottles. 

If the crystals be exposed to the air, they undergo liquefaction, 
and in consequence the purest phenol is usually prescribed in minim 
doses rather than in grains. It is soluble in alcohol, ether, chloro- 
form, glycerin, and most oils. It unites with alkaline bases to form 
salts, carbolates; but these are readily decomposed, even by the feeblest 
acids, such as carbonic acid. 

Physiological Action. — Locally applied to the skin, phenol produces 
at first a burning sensation, accompanied by a diffuse reddening of the 
surface. If the solution be strong, the part at once becomes tem- 
porarily painful, then bleached and numb, so that tactile sensibility 
is destroyed. Applied to mucous membranes, it causes similar 
changes, but to a more marked degree, and may even act as a moder- 
ately severe caustic of a superficial type. Owing to the coagulation 
of albumin produced when it is applied, it cannot cauterize the tissues 
very deeply. 

Nervous System. — Phenol acts as a depressant and paralyzant 
to the peripheral sensory nerves when locally applied. 

Upon the higher centres in the brain the acid produces a con- 
dition of depression and stupor. 

The convulsions which sometimes occur after toxic doses have been 
taken are spinal in origin, as they occur after section of the spinal 
cord. The motor nerves escape almost untouched, as do also the 
muscles. Convulsions rarely develop in man. 

Circulation. — Upon the circulation in the higher animals the 
drug exercises a distinct depressant influence, stopping the heart in 
diastole in lethal dose, and paralyzing the vasomotor centre even be- 
fore the cardiac muscle is affected. These changes follow only lethal 
doses. Small medicinal doses have no effect of any moment upon 
the circulation. 

Respiration. — After large doses the breathing becomes more 
rapid and full. These changes, according to Salkowski and others, 
are due to stimulation of the respiratory centres and the peripheral 
vagi. Lethal doses almost invariably kill by failure of respiration 
due to depression of the respiratory centres. 

Temperature. — Phenol acts as a feeble depressant to normal 
bodily temperature even when given in medicinal dose, and also 



430 DRUGS. 

decreases the bodily heat in fever. It lowers fever by diminishing 
heat-production and increasing heat-dissipation. This antipyretic 
power is hardly sufficient to permit of its use in disease for this 
purpose. 

Kidneys and Elimination. — When phenol is given in overdose, 
the kidneys may become so irritated that total urinary depression may 
occur. When taken in large quantity, it causes the urine to become 
brownish-black. This discoloration is due to an educt of phenol 
which is not yet isolated, perhaps hydrochinon. Phenol is eliminated 
in the urine as phenol-sulphonate of sodium and potassium and as 
glyco-uronic acid and hydrochinon. Part of it is burnt up in the body. 

It is to be distinctly understood that the dark urine of phenol 
poisoning is not due to the presence of blood or of any of its educts. 

Poisoning, Prolonged and Acute. — As the changes produced in the 
tissues of the body by acute and subacute poisoning by phenol are 
in many respects identical, they may be considered together. 

Phenol is one of the most deadly and rapidly acting poisons 
known, although this fact does not seem to be generally recognized. 
If a large lethal dose be swallowed by a man, he may drop dead 
from its effects before he can go more than a few feet from the spot 
where he stood when drinking the drug, or he may live a few hours. 
In cases where death has occurred suddenly from taking this acid 
the direct cause has been failure of respiration. If the patient does 
not die at once, all the evidences of gastro-enteritis come on. Violent 
vomiting and purging may ensue, and burning pain in the entire abdo- 
men is a prominent symptom. The skin is wet with sweat, the face 
pinched and anxious. Collapse, with a thready, imperceptible pulse 
and extreme dyspnoea, may be present. The mouth and lips may 
not smell of the drug, but the mucous membrane will be seen to be 
corrugated and stained black if impure acid has been taken, or be 
whitish if the pure drug has been used. The eschar on the mucous 
membrane is a peculiar one, and is pathognomonic of the poison, 
having a white centre surrounded by a reddened and inflamed zone, 
the centre sometimes becoming dark brown or black. The post- 
mortem will show these spots in the oesophagus and stomach, and 
even in the intestines. All the internal organs, as the brain, kidneys, 
liver, and spleen, will be found filled with dark grumous blood, and 
on opening the body the odor of the acid will be perceived. A 
peculiar croupous exudate is sometimes found in the bronchial tubes, 
and fatty degeneration of a more or less widespread type often follows 
phenol poisoning. Langerhans has noted that in some of these cases 
evidences of croupous pneumonia exist. A very common symptom 
is hoarseness of the voice due to an effect on the larynx after the drug 
is absorbed, and not from its local influence. 

A large number of cases are on record in which subacute phenol 
poisoning has been produced by its absorption from surgical dressings. 



PHENOL. 431 

The earliest signs of such an accident are the darkened, smoky hue of 
the urine and slight nervous unrest or cerebral disturbance. Very 
often pain in the lumbar region indicates kidney irritation. The 
dressings should be, of course, at once removed. 

Treatment of Poisoning. — The chemical antidotes to phenol are 
generally considered to be any non-poisonous soluble sulphate such as 
Epsom or Glauber's salt, which are supposed to form insoluble sulpho- 
carbolates, the latter being preferable to other soluble sulphates in that 
they also act as purgatives if freely used. Sollman and others have 
recently asserted, as the result of an experimental investigation, that 
the sulphates are useless, but there seems to be strong evidence that 
these soluble sulphates are of value in some instances at least. In 
those instances in which the symptoms are subacute, the venous injec- 
tion of sodium sulphate may do much good because the acid combines 
with the soluble sulphate and so is rendered harmless. The further 
treatment consists in hot applications to the extremities, the hypo- 
dermic injection of cardiac and respiratory stimulants, such as digitalis 
and strychnine, intravenous injection of normal saline, and the use of 
morphine to relieve pain. The stomach-pump should be used if possible. 

When phenol has been spilled on the hands, its effect can be overcome 
if the hands are immersed at once in absolute alcohol. There is no 
satisfactory explanation of this extraordinary effect. Alcohol is useless 
as an antidote when phenol has been swallowed. 

Therapeutics. — Internally phenol is little used, but, nevertheless, 
has a very favorable effect in certain states. In nervous vomiting or 
in that due to gastric irritation the drug does good in J to 2 minims 
(0.03-0.12) doses by depressing the sensory nerves in the stomach. 

In diarrhoea depending upon fermentation from 2 to 4 minims 
(0.10-0.25) of phenol do great good, particularly if combined with 10 
to 20 grains (0.60-1.30) of bismuth administered in powder or capsule. 

In gangrene and tuberculosis of the lung a spray of phenol in water 
in the strength of 5 to 15 minims (0.3-1.0) to the ounce (30.0) may 
do some good, and at least control the cough and relieve the irritation 
and tickling in the throat. 1 (See Part III., Inhalations.) Creosote is, 
however is, generally preferred in these conditions at the present 
time. 

In diphtheria, ulcerated sore throat, and even in ordinary stomatitis, 
phenol will be found of value when used in a spray or mouth-wash in 
the proportion of 1 part to 75 parts of water; and in ordinary sore 
throat or that due to sepsis, in the strength of 1 part to 100 of water it 
will be found, when applied on a swab or by a gargle, to relieve the 
pain and inflammation. By means of a stick it may be applied pure 
to the spots in aphthous stomatitis. In the treatment of burns phenol- 
ized sweet oil in the proportion of 1 drachm (4.0) of the drug to each 

1 The spray must be a very fine one, or it will not carry the drug far enough down into the 
lungs to be efficacious. 



432 DRUGS. 

6 ounces (180.0) makes one of the best dressings that can be used. 
By means of the local anaesthesia produced by the drug, minor opera- 
tions, such as eversion of an ingrowing toe-nail or opening a felon, may 
be performed by applying the pure drug by means of a brush to the 
line of the incision. Phenol may be used as a lotion in the itching of 
jaundice in the proportion of 10 grains (0.60) of the drug to 2 drachms 
(8.0) of glycerin and 2 drachms (8.0) of water, or, better still, 4 drachms 
(16.0) of sweet oil. 

In the form of an ointment phenol may be used in the strength of 
10 minims to the ounce (0.60-30.0) of a simple cerate, particularly in 
cases of subacute eczema where there is a great amount of weeping. 
In cases of eczema with much itching, and in pruritus and lichen planus, 
the following ointment is useful: 

1$ — Mentholis gr. v (0.30). 

Phenolis gr. x (0.60). 

Unguenti aquse rosas §j (30.0). — M. 

S. — Apply locally. 

Several clinicians have recommended the treatment of smallpox by 
touching the vesicles in limited areas each day with a small brush or a 
stick dipped in the pure drug. It is claimed that in this way pustu- 
lation is decreased, secondary fever is diminished, and pitting is 
lessened. 

In enlarged glands which have not gone on to suppuration intra- 
glandular injections of phenol by means of a hypodermic needle are 
of value in a large number of cases, the solution used being no weaker 
or stronger than 2 per cent. ; 5 to 10 minims (0.30-0.60) of this solu- 
tion are sufficient for each gland. In the treatment of buboes 10 min- 
ims (0.6) of a solution of 8 grains (0.5) to the ounce (30.0) may be 
injected into the swelling, the skin being first benumbed by an ether 
spray. This is a most successful treatment. The same treatment 
may be applied in chronic synovitis and repeated every three days, and 
boils and carbuncles may also be so treated with great success if this 
measure be used early enough to abort the trouble. 

Phenol is rarely used directly over wounds in dressings at present 
unless the dressing be one of phenolized oil. Other drugs, or rigid 
asepsis, have supplanted it when used in this way, but surgeons have 
returned to its employment as a useful antiseptic when used in pure 
form to swab out open wounds that are infected. The use of the 
phenolized spray over wounds has been found to do more harm than 
good, and it ought never to be employed. 

A valuable application for burns, small wounds, and abrasions that 
are probably infected is one composed of phenol and camphor. Three 
parts of camphor and 1 part of phenol are mixed, the crystals of phe- 
nol being first liquefied by heat. The mixture after several hours 
becomes perfectly blended and part of its odor is dissipated if the 
bottle holding it is left open for a few days. This preparation will 



PLATE I 




PHENOL GANGRENE. 



Appearance of a finger four weeks after the appli- 
cation for twenty-four hours of a dilute solution of 
phenol. The finger was wrapped in cloths which were 
saturated with the carbolic solution not stronger than 
five per cent. Amputation necessary. Inflammatory 
process at the base of the finger shown by the reddened 
tissues. (Harrington's case.) 



PHENOLSULPHONATES OF ZINC AND SODIUM. 433 

not harm the tissues nor cause pain as phenol does when not mixed 
with camphor, and may be applied with absorbent cotton or gauze 
or with petrolatum. Applied undiluted it is a useful application in 
tonsillitis in its early stages. 

As a disinfectant phenol ranks among the poorest: 1 to 2 per cent, 
solutions, however, kill most spores and germs. 

Untoward Effects. — Phenol when applied as a dressing, even in as 
weak a strength as 3 per cent., to a finger or toe may cause gangrene 
of the part severe enough to destroy it or to require amputation, but 
my dermatological colleague Dr. Stelwagon tells me that he has never 
seen this untoward effect although he often so employs the drug. Such 
strengths applied to the skin of the trunk rarely produce evil effects, 
probably because the circulation is not so completely cut off by the 
action of the drug on the bloodvessels. (See Plate I.) 

Administration. — Phenol ointment (Unguentunl Phenolis, U. S.; 
Ungucntum Acidi Carbolici, B. P.) and the glycerite (Glyceritum 
Phenolis, U. S.) and liquefied phenol Phenol Liquej actum, U. S.) are the 
only official preparations of phenol in the U. S. P. In the B. P. the 
following preparations are official: Aciclum Carbolicum Liqne factum, 
given in the dose of 1 to 2 minims (0.05-0.10); Glycerinum Acidi 
Carbolici, Trochiscus Acidi Carbolici, and Suppositorium Acidi Car- 
bolici. 

PHENOLPHTHALEIN. 

Phenolphthaleinum, U. S. and B. P. (C 2 oHi 4 4 ), originally used as 
a test for acids and alkalies, has come to be generally employed by 
many practitioners as a satisfactory laxative to overcome habitual 
constipation. It may be given alone in pill or tablet or combined with 
aloes. When given in the ordinary dose of 1 to 2 grains (0.06-0.12) 
at bedtime it produces a free, normal evacuation without pain or 
griping and produces no effect on the general system even when given 
over a long period of time. It is eliminated almost entirely in the 
feces. 

PHENYL SALICYLATE. 

(See Salol.) 

PHENOLSULPHONATES OF ZINC AND SODIUM. 

The phenolsulphonates of zinc {Zinci Phenolsulphonas, U. S.) and 
sodium (Sodii Phenolsulphonas, U. S.) are largely employed by some 
practitioners as mild antiseptic local stimulants, either in powder or in 
solution, on ulcers and sores. Much more commonly they are given 
internally for the production of gastro-intestinal antisepsis when there 
is diarrhoea with fetid, ill-smelling stools, as in the bowel disorders of 
hot weather in children or adults, or in the course of typhoid fever. 
How much good they do in the latter disease, so far as the disease itself 
28 



434 DRUGS. 

is concerned, is uncertain, but they undoubtedly render the stools less 
foul and tend to check the diarrhoea. The phenolsulphonate of zinc is 
the better of the two for these purposes. The dose is 2 to 3 grains 
(0.12-0.20) in pill four or five times a day. The phenolsulphonates 
are probably eliminated from the body unchanged. Sometimes good 
results follow the use of cascara sagrada with these salts in cases of 
constipation with flatulence and signs of autointoxication. 



PHOSPHORIC ACID. 

The pure acid is rarely employed in medicine, but when given 
is used in 2- to 8-minim (0.1-0.5) doses. In the form of dilute phos- 
phoric acid (Acidum Phosphoricum Dilutum, U. S. and B. P.) it is 
widely employed in the dose of 20 minims to 1 drachm (1.3-4.0), 5 to 
20 minims (0.3-1.2), B. P. ; as a tonic and gastric stimulant. It is not a 
food to the nervous system, does not resemble phosphorus in its physio- 
logical action, and is not to be employed in its place. It does good in 
nervous exhaustion simply by stimulating the stomach and thereby 
aiding that organ in the digestion of food. Phosphoric acid is also 
official in the B. P. as Acidum Phosphoricum Concentratum. 



PHOSPHORUS. 

Phosphorus, U. S. and B. P., is a non-metallic element, generally 
obtained from bones, and is very soluble in oils, less so in ether and 
alcohol. Its odor is characteristic and peculiar. When placed 
in a dark room after exposure to light it is luminous, and if exposed 
to the air will ignite. It should be kept under water in tightly- 
stoppered bottles. Very commonly it is contaminated by arsenic and 
sulphur. 

Physiological Action. — Phosphorus is found in large amount, com- 
paratively speaking, in the bones and in the nervous system, and is a 
stimulant to the growth of both. It acts, therefore, as a direct tonic 
to nervous tissue and is a producer of bone. Upon tissue-waste the 
drug acts as a depressant, thereby preserving the body, as it decreases 
the elimination of urea and diminishes the quantity of carbonic oxide 
exhaled. 

Upon the growth of bones phosphorus has a most remarkable 
influence, causing, when it is given to young animals, great increase 
in the size of these parts. The first change noted is an enlargement, 
which consists in a jelly-like mass containing little or no bone salts, 
and this is finally converted into a very hard material which may fill 
the entire canal in the centre of the bone. Kissel has stated that this 
does not occur, but his results must be doubted in view of the thorough 
studies of Wegner, 



PHOSPHORUS. 435 

Acute and Chronic Poisoning. — When phosphorus is taken in poi- 
sonous dose, often from the ends of matches, no symptoms may come 
on for eight or ten hours. At the end of that time the peculiar taste 
of phosphorus may be noted in the mouth, the breath is heavily laden 
with its odor, and burning pain in the oesophagus, stomach, and abdo- 
men becomes a pressing symptom. Vomiting and purging now assert 
themselves, and both the matters which are vomited and those which 
are passed from the bowels may be luminous in the dark, owing to the 
presence of phosphorus. The vomit at first consists of food, then 
mucus, then bile, and then perhaps blood. All the symptoms of a mild 
gastro-enteritis may develop, but it is to be noted that constipation of 
an obstinate type may be present instead of purging. Very soon the 
liver increases in size, and gives rise to general hypochondriac pain and 
tenderness as well as local swelling. At the end of twenty-four hours, 
or perhaps after the second day, a cessation in the symptoms occurs, 
and, if the physician be not on his guard, this will lead him to a hope- 
ful prognosis, but in the course of a few hours jaundice begins in the 
conjunctiva and then extends over the entire body. With the onset 
of jaundice the vomiting and pain return with renewed vigor. The 
matters vomited have often the color of ' coffee grounds," due to exuded 
and altered blood. The bowels are absolutely confined, or the few 
hard masses of fecal matter which are passed are white and clay-like 
because of the absence of biliary coloring matter. There is no bile 
in the vomit in this stage, because the hepatic ducts have been closed 
by the inflammation which has been produced in the liver. Later, 
nervous symptoms ensue. Muscular twitchings, headache, vertigo, 
wild delirium, erotic convulsions, and, finally, unconsciousness and 
death occur. Sometimes the convulsions occur just before dissolu- 
tion. Even if the patient survives the acute stage of the poisoning, he 
generally dies of the changes produced in his vital organs, which con- 
sist in widespread fatty degeneration. These fatty changes occur 
even in the acute form of the poisoning. Atrophy of the liver, destruc- 
tion of the gastric tubules, pancreatic involvement, and kidney degen- 
erations aid in producing the ultimately fatal results. 

During poisoning by phosphorus the urine is scanty and perhaps 
albuminous, and is peculiar because of the unusual substances which 
are found in it. The most unusual of these is sarcolactic acid, which 
results from breaking down of the muscular tissues. Leucin and 
tyrosin are also found, and tube-casts with fatty globules in them are 
seen. Free fat-globules may also occur. Bile acids and bile coloring- 
matter are found in large amount, and the urine is generally dark 
colored for this reason. As phosphorus is eliminated in the urine as 
hypophosphoric acid, this substance is also present. 

The symptoms of phosphorus poisoning may so closely resemble 
those of acute yellow atrophy of the liver as to make a differential 
diagnosis impossible unless some evidence of the presence of phos- 
phorus is obtainable. 

In chronic poisoning by phosphorus, usually caused by the inha- 



436 DRUGS. 

lation of its fumes, by far the most common lesion is necrosis of the 
lower jaw, which may be widespread or limited. The phosphorus 
by attacking the periosteum exposes it to infection, and pyogenic 



Fig. 61. 












: 



'^ 













& 



Showing the fat-granules produced in the liver in phosphorus poisoning. (Kast and Rumpler.) 

organisms attack the bone. Sometimes the tubercle bacillus causes 
the necrosis. Phosphorus necrosis never occurs in those who have no 
solution of continuity in the teeth or gums, and for this reason it is 
necessary that the employees in match factories should have their teeth 
and gums constantly attended to. It has been said that pans contain- 
ing turpentine when set around the work-room will protect the work- 
men, but this is certainly incorrect. Since laws have been passed for- 
bidding the use of yellow phosphorus in the making of matches this 
condition is very rarely seen. Some cases develop in the making of 
phosphor-bronze. The red amorphous phosphorus and the sesqui- 
sulphide used in safety matches is non-poisonous. 

Treatment of Acute Poisoning.— The antidote to phosphorus is 
generally taught to be the sulphate of copper, which will also act as an 
emetic if given in excess, but studies made by Thornton in my labora- 



PHYSOSTIGMA. 437 

tory at the Jefferson Medical College prove that when given in a dose 
large enough to be efficient it is as dangerous a poison as the phos- 
phorus. Peroxide of hydrogen or permanganate of potassium are 
probably the best antidotes, as they convert the phosphorus into phos- 
phoric acid. Oil of turpentine, in America, is not only valueless as 
an antidote, but harmful, for only old, ozonized French oil of turpentine 
is antidotal in its influence. As phosphorus is soluble in oils, we simply 
aid in its absorption if any such substances are given. 

Therapeutics. — Owing to its influence on the development of bone, 
phosphorus is very useful in rhachitis and osteomalacia. It is also 
useful in the siceats of general or nervous debility and in nervous ex- 
haustion, and in some cases of melancholia depending upon overwork. 
In the course of prolonged exhausting diseases, as typhoid fever or 
typhoid pneumonia, the drug is of service if the nervous system seems 
to be particularly affected, and in convalescence it is of service in aid- 
ing to build up the shattered forces of a patient. 

In the sequelae of acute and chronic alcoholism and in morphiomania 
it is of service. Phosphorus is also employed in sexual exhaustion 
or abuse. In boils and carbuncles and similar disorders phosphorus 
is very useful, particularly so in acne indurata. In pneumonia some 
physicians use minute doses with the belief that it aids in the produc- 
tion of resolution. Probably it does good in these cases by stimulating 
or supporting the nervous system. 

In the neuralgia from nerve-depression and in cerebral softening 
and meningitis of a chronic type phosphorus may be given with ad- 
vantage. 

The dose of phosphorus is y^- to -^ grain (0.0006-0.0012) in pill 
form (Pilule Phosphori, U. S. and B. P.), but it may be gradually pushed 
to 2V grain (0.003) if urgently needed. Phosphorated oil (Oleum Phos- 
phoratum, B. P.) and Spiritus Phosphori are given in the dose of 
1 to 5 minims (0.05-0.30). Elixir Phosphori is given in the dose of 
15 minims to 1 drachm (1.0-4.0). 

The beginning dose of phosphorus should not be above -j-J-q grain 
(0.0006), for fear of some idiosyncrasy. 

PHYSOSTIGMA. 

Physostigma, IT. S. (Physostigmatis Semina, B. P.), is a seed derived 
from Physostigma venenosum, a tree of West Africa, often called 
Calabar bean, yielding, when assayed by the U. S. P. process, not less 
than 0.15 per cent, of alkaloids. It contains two alkaloids, eserine or 
physostigmine and calabarine. The former is the more important 
from a medical point of view. 

Physiological Action. — When a very large dose of physostigma is 
given by the mouth it often produces some pain in the stomach and a 
sense of oppression and weakness. The pulse becomes slow, the respi- 
ration is depressed, and the pupils are contracted. Calabar bean in 



438 DRUGS. 

poisonous dose is a general paralyzant, but if the alkaloid calabarine 
be present in excess, it may be a convulsant. 

Nervous System. — On the spinal cord in poisonous dose this drug 
acts as a depressant poison, particularly affecting the sensory tracts. 
On the motor nerves it exerts no influence unless given in toxic doses, 
when it depresses their peripheral ends. The sensory nerves escape, but 
sometimes even they are involved. On the voluntary muscles the drug 
in these doses causes twitchings. In medicinal doses the drug is a stim- 
ulant to unstriped muscular fibre and acts as a mild nervous sedative. 

Circulation. — Calabar bean causes little circulatory change, but 
poisonous doses at first produce a rise of arterial pressure, due to a 
direct stimulation of the heart and of the muscular coats of the vessels. 
It slows the pulse by peripheral stimulation of the vagi. In medicinal 
dose its circulatory effect is not marked, but is depressant rather than 
stimulant. 

Respiration. — In moderate amount calabar bean does not affect 
respiration, but in poisonous dose it produces death by paralysis of 
the respiratory centre. 

Pupil.— Physostigma causes myosis or contraction of the pupil by 
stimulation of the circular muscular fibres of the iris, and not by depres- 
sion of the sympathetic fibres, nor by stimulation of the oculomotor 
fibres, nor again by causing contraction of the bloodvessels of the iris. 
It decreases intraocular tension, produces temporarily an increase in the 
power of accommodation for near objects, and then causes spasm of 
accommodation. The myosis usually develops in about eight to four- 
teen minutes after the drug is dropped into the eye, and reaches its 
maximum in thirty minutes, lasting for from six to eight hours. The 
partial influence may last, however, for four or five days. 

Alimentary Tract. — Physostigma is a stimulant to intestinal 
peristalsis, increasing the muscular activity in the walls of the gut 
and acting as a tonic to these fibres. 

Poisoning. — Poisonous doses of physostigma cause muscular trem- 
ors, followed by complete muscular relaxation. The pupils contract, 
the respirations become slow and irregular, and all reflex action fails. 
Vomiting or purging may or may not occur. 

Treatment of Poisoning. — This consists in the use of atropine, 
which is the physiological antidote; in the application of heat to the 
body, and the use of respiratory and cardiac stimulants, such as digi- 
talis, alcohol, or ammonia. 

Therapeutics. — Calabar bean has been employed in many affections, 
such as trismus neonatorum, tetanus, and other spasms, with only mod- 
erately good results. It is, however, of value in atony of the bladder 
and intestine and in catarrh of the bowels. Combined with nux 
vomica the author has used eserine with advantage in cases of gastric and 
intestinal dilatation. Some physicians think it of value in cases of 
tympanites, but in a limited use of it in certain severe cases of pneumonia 
with tympanites the writer has not found it of value. 



PICRIC ACID. 439 

It has also been used advantageously by surgeons to overcome 
post-operative tympanites in the dose of -£§ grain (0.002) by hypodermic 
injection with or without strychnine. 

In bronchial asthma and emphysema it aids in expulsion of, the mucus 
by its influence over the muscular fibres in the walls of the air-tubes. 
It is also useful in purgative pills to stimulate the muscular fibres of the 
intestine. (See Constipation.) 

In the eye, in the strength of 1 to 2 grains to the ounce (0.06-0.12 : 30.0) 
of water, eserine is used in the treatment of corneal ulcerations, for 
the relief of glaucoma, and to diminish high intraocular tension. If. 
for any reason, atropine mydriasis is to be rapidly overcome, eserine 
may be used, but it is not so powerful a myotic as atropine is a 
mydriatic, and it requires larger amounts of the solution to produce 
contraction than it took of atropine to cause mydriasis. 

Administration. — Physostigma is used in the form of the extract 
(Extractum Physostigmatis, U. S. and B. P.) in the dose of \ grain 
(0.008, which may be readily increased to \ grain (0.015), J to 1 grain 
(0.015-0.06), B. P. This extract should contain 2 per cent, of ether- 
soluble alkaloids. 

The tincture (Tinctura Physostigmatis, U. S.) should contain 0.014 
Gm. of ether-soluble alkaloids in 100 mils, and is given in the dose 
of 5 to 30 minims (0.30-2.0). _ 

Eserine is usually employed in the form of Physostigmince Salicylas, 
U. S., and may be used in the dose of -^ grain (0.0008) three times a 
day. The sulphate is much more soluble, and is generally to be 
employed. . The salicylate is largely used, nevertheless, by ophthal- 
mologists. Lamellw Physostigminw, B. P., each contain two g ram 
(0.00006) of phvsostigmine sulphate. The dose of both salts of 
eserine is yfo to Vo grain (0.0006-0.0008). 

PICRIC ACID. 

Picric acid, Trinitrophenol, U. S. (Acidum Picricum, B. P.), occurs 
in light yellow scales or needles without odor, and is chiefly used in 
the arts as a dye. Its uses in medicine are limited. It has been found 
exceedingly efficacious in solution in the treatment of severe burns 
and scalds. This solution is made as follows: 

]$ — Acidi picrici gr. lxxv-5ij (5.0-8.0). 

Alcoholis fgiiss (75.0). 

Aquae destillatae Oij (960 mils.). — M. 

After the burn is cleansed of dirt and charred clothing, strips of ster- 
ilized gauze are soaked in this solution and applied to the part. Over 
this is placed a pad of dry absorbent cotton which is fastened by a light 
bandage. The dressing rapidly dries, and may be left in place for 
several days. It is then moistened with the solution so as to soften it, 
is removed, and then a fresh dressing is applied for a week. All 
blisters should be pricked. At first the acid causes some pain, but in 



440 DRUGS. 

a short time this dressing relieves pain. It prevents suppuration, 
hastens healing, and results in a smooth cicatrix. As this dressing 
stains the hands, the physician should use rubber gloves when applying 
it. The existence of marked renal irritation should make us cautious 
in applying this acid solution to large surfaces, lest absorption occur. 

To remove the stain of picric acid from the skin, wash the hands in a 
solution of lithium carbonate in water in the strength of 1 drachm 
(4.0) to 1 quart (1000 mils.). 

PILOCARPUS. 

Pilocarpus, U. S., is the leaflets of a South American tree, Pilo- 
carpus microphyllus, or Pilocarpus jaborandi, yielding, when assayed 
by the U. S. P. process, not less than 0.5 per cent, of alkaloids. It 
contains two alkaloids, known as pilocarpine, and isopilocarpine. 
Jaborine is a combination of these alkaloids and a resinous substance. 
The alkaloid pilocarpine is non-crystallizable and occurs as a soft mass, 
but the salts of pilocarpine are crystallizable. 

Physiological Action. — When pilocarpus is taken in medicinal dose 
by a healthy man it causes a deep flushing of the face and neck, fol- 
lowed by the outbreak of a profuse sweat, which, though beginning 
in these regions, rapidly spreads over the entire body. Accompany- 
ing the sweat, salivation is often exceedingly profuse, so that saliva 
dribbles from the mouth. The sweat lasts from two to five hours. 
Nausea frequently comes on, and severe vomiting may appear in 
susceptible persons either during or after the sweating Some in- 
dividuals are singularly insusceptible to the diaphoretic influence 
of pilocarpus and this is particularly so, according to Ringer, with 
children, who will often take as much as 60 grains (4.0) of the crude 
drug before they perspire. 1 

Nervous System. — Moderate doses given to men have no effect on 
this part of the body. 

Circulation. — In large doses there is no doubt that jaborandi acts 
as a cardiac depressant rather than a stimulant. The drug causes 
in the lower animals a slow pulse and decreased arterial pressure, in 
moderate quantities, the first change being due to an action on the 
inhibitory centres in the heart or on the peripheral vagi. (See Fig. 
62.) In man the drug does not slow the pulse, but quickens it very 
markedly, often as much as 40 to 50 beats per minute. Although 
the*pulse in animals is generally made stronger by its use, in man it 
is generally made weaker. 

Stomach. — Jaborandi sometimes produces nausea and vomiting 
by irritating the stomach and perhaps the vomiting -centre. 

Temperature. — Jaborandi lowers bodily temperature to a con- 
siderable degree, probably by the dilatation of the peripheral capil- 

1 The writer has reported a case (see Idiosyncrasy) in which a woman of thirty years 
received f grain of the muriate of pilocarpine hypodermically in half an hour without 
any effect. 



PILOCARPUS. 



441 



laries and the profuse sweat which it produces. This fall is sometimes 
preceded by a brief rise. 

Kidneys and Tissue-waste. — Upon the kidneys jaborandi acts 
very slightly or very strongly, according to the dose that is given. 
Large doses, which produce a profuse sweat, naturally decrease the 
urinary secretion, but small ones undoubtedly increase it. Upon the 
tissue-changes in the body under pilocarpine no researches have been 
made, but it is an undoubted fact that in disease the excretion of urea 
is largelv increased under the influence of this drug. 

Fig. G2. 



\i\(WW\q|WV 



ii 



in 



IV 




Parts CK a tracing showing the effect of pilocarpine in depressing blood-pressure, and the stimu- 
lant effect of atropine upon blood-pressure in the circulation of a dog. (After Schmiedeberg.) 
I. Shows the pulse-rate and blood-pressure unaffected by drugs. II. Pilocarpine injected, which 
slows the pulse from 28 in ten seconds to 19 in ten seconds, and lowers the blood-pressure from 
126 to 96. III. Further depression and slowing; pressure, 70. IV. Atropine given, which raises 
blood-pressure to 145 and pulse-rate to 30. 

Eye. — Jaborandi contracts the pupil by stimulating the peripheral 
ends of the oculomotor nerve in the iris. 

Skin and Secretion. — The amount of sweat caused by the drug 
in man may equal as much as a pint, and it is generally first acid, from 
the secretions of the sebaceous glands, then neutral, and finally alka- 
line. The sweating is not primarily due to vasomotor palsy, but to 
stimulation of the ends of the nerves supplying the glands and of the 
sweat-glands themselves. The sweat usually lasts about two or five 



442 DRUGS. 

hours. Sometimes excessive salivary secretion supplants that of the 
skin. 

Pilocarpine increases the gastric, salivary, and lachrymal secretions, 
as well as that of the skin and kidneys. It also seems to have con- 
siderable influence over the secretion of milk. 

Therapeutics. — Jaborandi, or, better still, its alkaloid, pilocarpine, 
is of some value for the relief of dropsy of the renal type. (See below.) 
In cardiac dropsy it is generally too depressing, and the author knows 
of more than one case in which a fatal result speedily followed its use 
under these circumstances. It may be used to abort an attack or 
paroxysm of malarial fever, but because of its depressant influence it 
should never be employed in asthenic fevers, such as typhoid fever. In 
pleurisy with effusion it has been used, but more efficient remedies are 
elaterium, or salines given in concentrated form and at the proper time 
of the day. (See Magnesium Sulphate and Dropsy.) Better than all 
these is thoracentesis. Spaulding and de Schweinitz have both recom- 
mended very highly the hypodermic use of pilocarpine in the dose of yj 
to jV grain (0.005-0.006) a day for opacities of the vitreous humor of 
the eye. The fluidextract of jaborandi may be employed, but is apt to 
nauseate the patient. Diaphoresis should not be produced. Because 
of its myotic influence on the pupil pilocarpine is of very great value 
in the treatment of all conditions of the eye associated with increased 
intraocular pressure. It is so good a myotic as to be rapidly supplant- 
ing eserine for this purpose with some clinicians. The strength of pilo- 
carpine solution for this purpose is 1 to 4 grains (0.06-0.25) to the 
ounce (30.0). It should be dropped into the eye, 1 or 2 drops at a 
time, every hour until the patient is relieved. Pilocarpine is also use- 
ful as an ocular tonic to relieve eye-pain after excessive use of the eyes, 
in the strength of -^ grain (0.006) to the ounce (30.0). A few drops 
of this solution may be dropped into the eye three times a day. This 
solution should have a little boric acid (4 grains) added to it to prevent 
fungus growth. (See Asthenopia.) Clinical reports show that pilocar- 
pine in small doses is a good remedy in tobacco and alcoholic amblyopia. 

Mitkowski has tried pilocarpine in catarrhal jaundice of a persistent 
type with great benefit, in the hypodermic dose of J grain (0.01) every 
other day for three weeks. In uremic poisoning pilocarpine is theoreti- 
cally the most efficient and rapidly acting remedy that we have, and 
when used in Bright' s disease it may be of value; but the frequency 
with which its use has been followed by pulmonary oedema or a transu- 
dation of fluid into the bronchi has made many practitioners afraid to 
employ it. 

, Care should always be exercised in the use of the drug lest cardiac 
depression ensue, and alcohol or strychnine may often be used with 
advantage to guard against this accident. The general consensus 
of opinion is that in the nephritis of middle or advanced life with 
cardiac changes it is contraindicated. The author never uses it in 
chronic parenchymatous nephritis. In the convulsions of preg- 



PILOCARPUS 443 

nancy pilocarpine, while theoretically useful, has been proved by 
experience to do more harm than good through its depressing influ- 
ences, although the drug in small doses often increases renal activity. 
The hypodermic dose of pilocarpine as a renal stimulant should be 
about -jo- to 2V grain (0.002-0.003) . In some forms of profuse sweating, 
such as come on at night in cases of general debility, pilocarpine, 
if given hypodermically or by the mouth about two hours before 
the sweat in the dose of 2V grain (0.003), is often useful even where 
atropine fails. The good effect is produced by stimulating the sweat- 
glands and so overcoming their atony. 

J. M. Da Costa and Barr have highly recommended the hypo- 
dermic injection of pilocarpine in erysipelas as a preventive and cura- 
tive measure in the early stages of this disease, and their reports are so 
encouraging as to warrant a careful trial of the method. The proper 
dose is J grain (0.01). every three hours until free sweating ensues. 
After this is accomplished the doses may be repeated every four or six 
hours. The author would fear that such active treatment might 
seriously affect the strength of the patient unless stimulants were 
also used. 

In cases of obstinate aural vertigo a most efficient treatment is the 
hypodermic use of pilocarpine every few days in sufficient dose to pro- 
duce some salivation. The patient must lie down or go to bed after 
the dose is given. 

Pilocarpine certainly has a decided effect in encouraging the growth 
of hair, and applied locally will often do good in partial baldness. If too 
much pilocarpine is used, it is apt to cause the development of small 
pustules about the hair-follicles. Bartholow recommended the follow- 
ing application or baldness : 

I^—Fluidextracti pilocarpi foj (30.0). 

Tincturse cantharidis ...... f §ss (16.0). 

Linimenti saponis f oiss (45.0).— M. 

The author has found the following prescription very efficacious in 
falling of the hair: 

1$ — Fluidextracti pilocarpi f 3j (4.0). 

Tincturse capsici foj (30.0). 

Tr. cantharidis f 3ss (2.0). 

Olei ricini foj (4.0). 

Alcoholis q. s. fgiv (120.0).— M. 

S. — Apply with friction in spots to the scalp, night and morning. 

Antagonisms of Jaborandi. — Jaborandi is a physiological antidote 
to atropine and to agaricin. Four times the dose of pilocarpine must 
be used to counterbalance a dose of atropine. Vomiting produced by 
pilocarpus is to be antagonized by morphine. 

Untoward Effects. — Dimness of vision, vomiting, sudden collapse, 
swelling of the salivary glands and tonsils, hiccough and strangury 
are sometimes met with after using pilocarpus. Sometimes bloody 



444 DRUGS. 

leucorrhoea is seen. The vomiting can usually be prevented by full 
doses of chlorodyne. Occasionally pulmonary oedema develops. 

Prentiss has called attention to the fact that the continued use of 
pilocarpine may cause the hair to become coarse and dark. 

Administration. — The dose of jaborandi is 40 grains (2.6) used in 
the form of the powdered leaves in infusion. The fluidextract {Fluid- 
extractum Pilocarpi, U. S.; Extractum Jaborandi Liquidum, B. P.) 
contains 0.4 Gm. of the alkaloids of pilocarpus in each 100 mils., and 
should be used in the dose of 10 to 40 minims (0.60-2.6), 5 to 15 
minims (0.3-1.0), B. P. Pilocarpine is far superior to jaborandi, in 
that it does not so often produce nausea and vomiting. It is used in 
the form of the hydrochloride (Pilocarpine Hydrochloridum, U. S.), 
in the dose of from J to ^ grain (0.008-0.03) hypodermically, or \ to \ 
grain (0.015-0.03) by the mouth and in the form of the nitrate {Pilo- 
carpine Nitras, U. S.) in the same dose as the hydrochloride. 

The additional preparations of the B. P. are — the tincture (Tinc- 
tura Jaborandi), dose \ to \ fluidounce (8.0-16.0); and the nitrate of 
pilocarpine {Pilocarpine Nitras), J to i grain (0.008-0.03). 



PIMENTA. 

Pimenta or Allspice is the nearly ripe fruit of Pimenta officinalis, 
a tree of the West Indies. It contains an official volatile oil {Oleum 
Pimentce, U. S. and B. P.), used for flavoring purposes, as a con- 
stituent of spice plasters, in diarrhoea mixtures, or as a carminative. 
It will also prevent the griping of purgative medicines. The dose of 
the oil is 1 to 5 minims (0.06-0.30). Aqna Pimentce (B. P.) is given in 
the dose of 1 to 2 ounces (30.0-60.0). 



PIPERAZINE. 

Piperazina is a substance, the chemical formula of which is C 4 H 10 N 2 , 
introduced into medicine for the treating of the so-called uric-acid 
diathesis. It is not stable, and when exposed to the air attracts 
water and carbonic acid; so it must be kept in tightly-stoppered bottles. 
Aqueous solutions are decidedly alkaline, but do not have any distinct 
taste. 

Piperazine is peculiar in its power to dissolve uric acid, dissolving 
twelve times as much as will carbonate of lithium, and it is also 
entirely soluble in water, which lithium is not. When taken into the 
body the drug is partly oxidized and partly eliminated unchanged. 
Theoretically, piperazine, when taken into the body, forms with uric 
acid a urate of piperazine, which is soluble and readily eliminated. 
Experiments to determine this point have been made with very satis- 
factory results, and repeated clinical observation has shown that the 



PISCIDIA ERYTHRINA. 445 

administration of the drug causes an increase in the amount of urea 
in the urine with a decrease in the uric acid, indicating that under its 
influence oxidation is more complete. 

Therapeutics. — Piperazine is used for the purpose of preventing the 
formation of renal and vesical calculi in the so-called uric-acid diathesis, 
and also in cases where the excess of uric acid in the urine tends to 
produce irritation of the bladder. Similarly, its action has been found 
of value in treating vesical irritation due to this cause by washing out 
the bladder with a solution of piperazine of the strength of 1 per cent. 
Piperazine has also been injected into uric-acid deposits about the 
body or applied to the broken-down surfaces of these deposits in 1 
per cent, solution, but the author has not been favorably impressed 
with this method, and would advise against its use — first, because it 
does little if any good, and, second, because the method is painful 
and apt to cause sloughs by interfering with nutrition of the skin, 
which is already lacking in health. 

The dose of piperazine is 15 grains (1.0) in twenty-four hours. It 
is best given by dissolving this amount of the drug in 1 pint (480 mils.) 
of water, and directing the pat'ent to take a wineglassful of the solu- 
tion frequently through the day. Owing to the effect upon the drug 
of exposure to air, it cannot be given in pill or powder, and should 
be freshly mixed each day. The writer has failed to obtain any results 
from the use of this drug in his practice. 

Stewart has noted, as untoward effects of full doses of piperazine 
tremors, hallucinations, and clonic spasms. 

Lycetol is a substance closely allied to piperazine, and is used in 
medicine for the same purposes. Dissolved in water it has a taste 
somewhat like lemonade. Unlike piperazine, it is not hygroscopic and 
will keep indefinitely. The dose of lycetol is 15 to 30 grains (1.0-2.0) 
a day, well diluted with water, to which a little sugar may be added to 
improve the taste. Usually it is best to give the drug in carbonated 
water, and to begin with small doses, which are to be gradually in- 
creased in size. 

PISCIDIA ERYTHRINA. 

Piscidia Erythrina is a drug which is stated to possess marked nar- 
cotic and pain-relieving properties. It is sometimes called Jamaica 
dogwood. Its powers as a soporific and analgesic do not compare 
with those of opium, but it is stated to be devoid of the unpleasant 
after-effects of the latter drug. Further studies concerning its effects 
on the animal economy are needed. According to Dr. Isaac Ott and 
Dr. Nagle, the drug has little or no effect on the motor and sensory 
nerves, and its dominant effect on the circulation is to increase arterial 
pressure through stimulation of the vasomotor system. The indica- 
tions which have been met best by piscidia are dysmenorrhea due to 
irregular flow and spasm of the uterine cervix and fundus, to allay 
nervous irritability, and to relieve pain or insomnia due to pain. 



446 DRUGS. 

Administration. — The dose of the fluidex tract of piscidia erythrina 
is J to 2 drachms (2.0-8.0); of the solid extract, 2 to 10 grains (0.12- 
0.6). The alkaloid, piscidine, is not known to represent all the prop- 
erties of the drug, and is not used in medicine. 

PITCH. 

Pix is a resinous exudation derived from several species of pines, 
firs, and spruces, and is, in one of its forms, obtained by the evapora- 
tion of wood-tar. It is used for various purposes, according to its deri- 
vation. Burgundy Pitch (Pix Burgundica, B. P.) is derived from 
Norway spruce, or Abies (Picea, B. P.) excelsa, a plant of Europe 
and Asia. It softens and melts at the temperature of the body and is 
useful for plasters. In muscular rheumatism and in chronic bronchitis 
pitch is a mild and fairly useful local remedy for external use. In 
the form of the plaster (Emplastrum Picis, B. P.), and in the form 
of warming plaster (Emplastrum Picis Cantharidatum), it is employed 
for the relief of deep-seated sprains and bruises, and acts as a mild 
counterirritant, which may blister a tender skin. Canada pitch (Pix 
canadensis) is obtained from the hemlock spruce of Canada and 
the United States, and is used for the same purposes as Burgundy 
pitch. The Canada-pitch plaster (Emplastrum Picis Canadensis) is 
employed for the same conditions as the plaster of Burgundy pitch. 



PITUITARY GLAND. 

The posterior lobe (infundibulum) of the pituitary gland is now 
largely used in medicine. In dried form it is official in the U. S. P. 
as Hypophysis Sicca, and a liquid extract is also official as Liquor 
Hypophysis, U. S. The preparation in liquid form, most generally 
used for all purposes is called "pituitrin." 

The physiological action of this substance is almost identical with 
adrenalin in that it is a stimulant to the heart and the muscular 
coats of the bloodvessels, but its action, although more prolonged 
than that of adrenalin, is less powerful and less sudden in onset. It 
slows the pulse rate. Locally applied to mucous membranes it 
induces a similar ischsemia to that caused by adrenalin. Upon the 
parturient uterus after the os is dilated it acts as a powerful stimu- 
lant. It also stimulates intestinal peristalsis and the muscular coats 
of the bladder. It increases urinary flow, not by stimulating the 
epithelium of the kidney, but by increasing the blood-pressure in the 
renal vessels. It also in some cases increases the secretion of milk. 

Therapeutics. — Pituitrin for the reasons just given finds its chief 
use as an oxytoxic which is not to be given until the os is dilated to the 
size of a quarter of a dollar and until the physician is sure that the birth 
canal is not obstructed, Its action is so prompt that after it is given 



PITUITARY GLAXD. 



44; 




448 DRUGS. 

the physician should not leave the patient. If after its use labor 
threatens to be too precipitate, chloroform should be given. It has 
largely displaced the forceps in slow labor due to feebleness and 
uterine inertia. This drug is also used as a circulatory stimulant in 
collapse, to control surgical shock, for the relief of postoperative intestinal 
torpor and to remove tympanites in the course of the acute infectious 
diseases. It is also used in atony of the bladder. When used as an 
oxytoxic the dose is usually 5 to 10 minims (0.3-0.65), but twice or 
thrice these amounts are used to stimulate peristalsis. Where used 
locally to constrict engorged mucous membranes, as in hay fever and 
acute rhinitis, it is best to dilute it from three to ten times with normal 
salt solution. 

A considerable number of cases of diabetes insipidus have been 
greatly benefited by the hypodermic use of pituitrin. 

The exact physiological and therapeutic value of the anterior lobe 
of the pituitary body is still undetermined. It would seem to be 
indicated in cases of delayed development in childhood, physical, men- 
tal, and sexual, particularly if there is an abnormal tolerance for 
sugar, so that when sugar is taken in excess glycosuria does not 
ensue. It is given in the form of the desiccated powder in the dose 
of 2 to 3 grains (0.1-0.25) three times a day. Some physicians have 
gone so far as to prescribe the anterior lobe for sexual atony in adults. 

PODOPHYLLUM. 

Podophyllum, U. S., May apple or mandrake, is the rhizome and 
small roots of Podophyllum peltatum, a plant of the United States and 
Canada. Podophyllum contains a resin, podophyllin. 

Therapeutics. — Podophyllum is the slowest-acting purge official in 
the Pharmacopoeia. In small doses it is laxative, but is purgative and 
almost drastic in larger amounts. In overdose it may produce gastro- 
enteritis. The drug particularly excites the flow of bile, and is used as 
a cholagogue. It is best given when the stools are dark in color, calomel 
being indicated when they are light. The author has found the follow- 
ing prescription useful in cases of intestinal flatulence and indigestion 
with constipation: 



1$ — Podophyllin . 
Euonymin . 
Leptandrin . 
Extracti chiratse 
Creosoti . 
Fiant pilulse No. xx. 



gr. v. (0.30). 
gr. v. (0.30). 
gr. v. (0.30). 
gr. xlv. (3.0). 
gr. x. (0.60).— M. 



In children one or two months old who have hard, stony stools podo- 
phyllin is a good remedy. The dose should be given by dissolving a 
grain of the resin in a drachm of alcohol and using 2 drops or more of 
this on sugar once or twice a day. In children who suffer from summer 
diarrhea, in which the passages consist almost entirely of water, which 
have a peculiar musty smell or a mouse odor, podophyllin in the 



POMEGRANATE. 449 

dose of -^ to 3V grain (0.001-0.0012), repeated every few hours, is 
of service, seeming to control the passages and make them normal. 
This treatment will often succeed when all else fails. This statement is 
also true in regard to the chronic diarrhoeas of adults, though the drug 
should be given in somewhat larger amounts in such cases. Podo- 
phyllin will also check vomiting in these doses in some instances, pro- 
vided that the stomach is depressed and the liver is torpid. It should 
not be employed if the vomiting is due to irritation or inflammation 
of the stomach. 

Administration. — Podophyllum is used in the form of the extract 
(Extractum Podophylli), dose 1 to 5 grains (0.06-0.30); the fluid- 
extract (Fluidextr actum Podophylli, U. S.), dose 2 to 20 minims (0.12- 
1.3); and more commonly than all, as the Resina Podophylli, U. S. 
Podophylli Resina, B. P., or podophyllin, which is the best preparation. 
The dose of this preparation is from -£§ to ^0 grain (0.003-0.006) as a 
feeble laxative, and from -^ to \ grain (0.006-0.03) as a purge, J to 1 
grain (0.015-0.06), B. P. The tincture (Tinctura Podophylli, B. P.) 
is given in the dose of to 15 minims (0.3-1.0). 

POMEGRANATE. 

Granatum, U. S., is the bark of the stem and root of Punica granatum, 
It is seldom used in America in its crude form. It contains an 
alkaloid known as pelletierine, this alkaloid being a colorless liquid, 
soluble in 20 parts of water and readily miscible with ether, chloroform, 
and alcohol. When to it acids are added it forms crystalline salts, 
of which four are used — namely, the tannate, the sulphate, the 
hydrobromide, and the hydrochloride. The first is most commonly 
employed, and is a yellowish powder possessing an astringent taste. 
It is soluble in 235 parts of water and 12.6 of alcohol. Its physio- 
logical action needs further investigation, but the drug in poisonous 
amounts paralyzes the peripheral ends of the motor nerves in a manner 
closely resembling the. action of curare. Sensibility is preserved. The 
loss of power is chiefly manifested in the lower limbs, in which at first 
there may be cramps. There may also be nausea and vomiting. 

Therapeutics.- — Originally, pomegranate was largely used in the form 
of the rind of the fruit in decoction as a vegetable astringent, but 
this practice has ceased because of its disagreeable taste and effect 
upon the stomach. The ailments which were supposed to indicate its 
employment were serous diarrhoea and profuse sweats. In some trop- 
ical countries the bark of the root is used as a vermifuge, and it is very 
efficient in removing the tape-tcorm. It is said that the bark of the 
root of the wild shrub is much more efficacious than that of the cul- 
tivated and more handsome plant. To be effective the dose of the 
decoction of the bark must be large. The drug is prepared by soak- 
ing 2 ounces (60.0) of the bark hi 2 pints (960) of water for twenty- 
four hours and then boiling down to a pint (4S0). A wineglassful 
29 



450 DRUGS. 

(30.0) of this is the dose which is generally given, and it may be repeated 
every hour until the whole amount is taken. The objection to this 
line of treatment is that it is unnecessarily severe, often purging and 
vomiting the patient excessively. The nausea produced is often great. 
Should purging fail to occur, it is necessary to give castor oil or other 
purge to dislodge the worm, and it is always necessary to starve the 
patient for twelve hours before the remedy is tried. 

The dose of pelletierine is 3 to 5 grains (0.20-0.30), and the tannate 
(Pelletierince T annas, U. S. and B. P.) is the salt usually employed. 
Practically, the only pelletierine used is the French preparation of 
Tanret. This preparation is put up in small vials; each contains a 
dose of 5 grains of the drug in solution ready to take. 

As large doses as 20 grains (1.3) of pelletierine have been used, 
but as serious paralytic symptoms have ensued after the ingestion of 
5 grains by a susceptible woman, not more than this amount should 
be given. When pelletierine is used, it should always be followed in 
two hours by a purge. Those who have used it most place great 
reliance on it. The fluidextract (Fluidextr actum Granati, U. S.) is 
given in the dose of 20 to 30 minims (1.3-2.0). The B. P. con- 
tains one official preparation of pomegranate — namely, the Decoctum 
Granati Corticis, the dose of which is 1 to 2 fluidounces (30.0-60.0). 



POTASSIUM ACETATE. 

PotassiiAcetas, U. S. and B. P., should contain, when thoroughly dried, 
not less than 98 per cent, of pure potassium acetate [KC 2 .H 3 2 ], and 
should be kept in well-stoppered bottles. 

It occurs in a white powder, or in crystalline masses of a satin- 
like lustre, odorless, and having a warming, saline taste. It is very 
deliquescent on exposure to the air. 

Soluble in 0.5 part of water, and in 2.9 parts of alcohol at 25° C. 
(77° F.); with increasing temperature it becomes much more soluble 
in both liquids. 

It was at one time largely used in the treatment of acute rheu- 
matism in the "alkaline method/' as when it enters the blood it is 
changed into an alkaline carbonate. It has been supplanted by the 
salicylates in the treatment of most cases of rheumatism. The dose 
should be from \ to 1 ounce (16.0-30.0) a day. A combination of 
10 grains (0.6) of the iodide of potassium and 30 grains (2.0) of the 
acetate is useful in subacute rheumatism in some instances. 

In hepatic torpor acetate of potassium is exceedingly efficacious, and 
aids in promoting the flow of bile as well as that of the urine. It 
has been used in the treatment of the so-called uric-acid diathesis, and 
quickly renders an acid urine alkaline. At one time it was supposed 
to purify the blood by aiding in the oxidation of effete material. 

The dose of potassii acetas is from 20 grains to 2 ounces (1.3-60.0), 



POTASSIUM BROMIDE. 451 

the latter dose being employed only when a purgative effect is desired; 
but other drugs are more suitable for this purpose. 



POTASSIUM BICARBONATE. 

This salt (Potassii Bicarbonas, U. S. and B. P.) is used for the 
same purposes as the citrate and acetate of potassium, and, as it is 
much less agreeable in taste, should not be employed when they can 
be obtained. From the bicarbonate of potassium are made several 
very useful preparations: the liquor potassii citratis, by adding 120 
grains (8.0) to 90 grains (6.0) of citric acid and 10 ounces (300.0) of 
water; the neutral mixture, by adding to 1 pint (480.0) of lemon-juice 
enough of the potassium salt to neutralize it. The dose of potassii 
bicarbonas is 5 to 40 grains (0.3-0.6), or even as much as 2 drachms 
(8.0) may be given if well diluted with water. 

POTASSIUM BITARTRATE. 

Potassii Bitartras, U. S., Potassii Tartras Acidus, B. P., is some- 
times called "cream of tartar," or acid tartrate of potassium. It is a 
white gritty powder which may occur in rhombic crystals. Owing to 
its stability, it escapes from the body without oxidation, and so 
differs from the other potassium salts formed by vegetable acids 
which are changed into alkaline carbonates. 

Therapeutics. — The bitartrate of potassium is the most diuretic of 
the potassium salts, and is used in heart disease with gin or com- 
pound infusion of juniper, for the purpose of removing dropsy. One 
ounce (30.0) of the salt is added to a pint (480 mils.) of the infusion 
of juniper berries, and the entire quantity taken in divided doses in 
twenty-four hours. In acute renal disease the drug should be used 
without the juniper and it should be remembered that if nephritis 
prevents the free excretion of the potash it may act as a serious depress- 
ant. In large doses — J ounce (15.0) — it acts as a watery purge, but 
is rarely so used. Where the urine is thick and alkaline, bitartrate of 
potassium is a useful remedy to acidify and make it clear and normal in 
appearance. 

A useful diuretic beverage called " Imperial Drink " is prepared as 
follows : 

Potassium bitartrate 1 ounce (30.0). 

Tartaric acid 1 ounce (30.0). 

Oil of lemon ... 12 minims (1.0). 

Sugar 16 ounces. 

Boiling water 1 gallon. Cool and strain. 



POTASSIUM BROMIDE. 

(See Bromide of Potassium.) 



452 DRUGS. 



POTASSIUM CARBONATE. 

Carbonate of potassium (Potassii Carbonas, U. S. and B. P.). This 
salt is never used in medicine, except to prepare other salts, as it is 
disagreeable to the taste and is an irritant. (See Potassium Citrate.) 



POTASSIUM CHLORATE. 

Chlorate of potassium (Potassii Chloras, U. S. and B. P.) is a salt 
of potassium differing entirely in its physiological action from all the 
other potassium salts, and, with the exception of the cyanide of potas- 
sium, is certainly the most poisonous. Not only is it, when locally 
applied, an irritant to mucous membranes, but when absorbed into 
the blood it causes changes of a serious character in this fluid, and 
produces acute nephritis if given in overdose. 

In dry form chlorate of potassium ought never be rubbed with 
organic substances in a mortar, as an explosion may occur. 

Physiological Action. — It has been thought by some that chlorate 
of potassium gives up a large amount of oxygen to the body, and that 
for this reason it would be of value in cases of slow asphyxia, such 
as results from pneumonia or phthisis. It has even been recommended 
to travellers crossing high mountains where the rarity of the air pro- 
duced disagreeable effects; but nothing is more absurd than the belief 
that it gives up oxygen to the body. Chlorate of potassium does give 
off oxygen when exposed to high heat, but not at the temperature of 
the body. Nearly all of it escapes from the body unchanged. 

When overdoses of the chlorate are taken, it produces sickness of 
the stomach, headache, pain in the loins and belly, dyspnoea, cyanosis, 
heart-failure, and great weakness. Poisonous doses cause the blood 
to be of a chocolate color, this change being due to the production 
of methsemoglobin. The blood-corpuscles are crenated and broken 
down, and after death the liver, kidneys, and spleen are found softened 
and filled with broken-down and disorganized blood. 

Therapeutics. — Chlorate of potassium is useful in stomatitis and in 
mercurial sore mouth as a mouth-wash, or given internally, in the 
following mixture: 

1$ — Potassii chloratis gr. xlviij (3.2). 

Tincture myrrhse f 3ss (2.0). 

Elixiris calisayse q. s. ad f 5iij (90.0). — M. 

S. — Teaspoonful (4.0) every five hours, or use as a mouth-wash. 

Owing to the fact that the drug is eliminated by the saliva to a great 
extent, the mucous membranes affected by stomatitis are constantly 
bathed by the solution of the chlorate when it is taken by the stomach. 
If any irritation of the stomach or kidneys exist, the medicament must 
be used on a swab and none of it swallowed. 

In diphtheria chlorate of potassium is very commonly employed, 



POTASSIUM CITRATE. 453 

but its use is dangerous. Death in many cases of diphtheria is 
aided by renal irritability, possibly by reason of an acute neph- 
ritis, and this drug simply increases the inflammatory process. If 
the chlorate of potassium is employed in diphtheria, it should be 
used in solution and applied by means of a swab. (See Diph- 
theria.) 

In acute follicular "pharyngitis chlorate of potassium is a useful 
gargle, and Wood recommends the use of a solution made by adding 
1 ounce (30.0) of sumach-berries, \ ounce (16.0) of chlorate of potas- 
sium, and 1 pint (480 mils.) of boiling water to each other, and 
allowing them to simmer for a few hours, when the mixture should be 
strained, cooled, and used as a gargle. 
The following is equally serviceable: 

1$ — Potassii chloratis 5j (4.0). 

Fluidextracti rhois glabra; f gss (16.0). 

Aqua destillatse q. s. ad fgiij (90.0). — M. 

S. — To be added to an equal quantity of water in a glass and used as a gargle 
every two hours, after stirring. 

This prescription makes an abominable-looking pharmaceutical prepa- 
ration, but is an exceedingly useful one. 

In acute rectal catarrh with mucous diarrhwa and tenesmus a solution 
of chlorate of potassium in water, 20 grains (1.3) to the ounce (30.0), 
injected into the bowel, will often produce a cure after one or two 
injections. Not more than 4 ounces (120.0) should be used, and it 
ought to be retained for twenty minutes. Often it will be well to add 
the saturated watery solution of the chlorate to an equal quantity of 
starch-water, as the latter aids in allaying the local irritation. This 
same method can be used in the treatment of hemorrhoids, and a few 
drops of laudanum, if added to this solution, will be found of great 
service. The troches (Trochisci Potassii Chloratis, U. S. and B. P.) 
are given in the dose of 1 to 6, each lozenge containing about 2J grains 
(0.15). They are intended to be dissolved in the mouth to affect the 
oral mucous membrane, but if many are used they are apt to dis- 
order the stomach by reason of an excess of the drug being swallowed 
in the saliva. 

POTASSIUM CITRATE. 

Citrate of potassium (Potassii Citras, U. S. and B. P.) is a white, 
granular, deliquescent salt, almost neutral in reaction and very soluble 
in water. It is by far the most agreeable of all the salts of potas- 
sium to the taste. In the early stages of bronchitis it is of the greatest 
value when combined with ipecac (see Bronchitis), and it is also use- 
ful as an alkaline diuretic. In bronchitis the dose should be 20 grains 
(1.3) every four hours, and in urinary incontinence due to acid and 
concentrated urine the dose should be equally large. 

Under the name of neutral mixture (Mistura Potassii Citratis), 
made by adding to 1 pint (480 mils.) of lemon-juice enough bicarbonate 



454 DRUGS. 

of potassium to neutralize it, we have a useful febrifuge drink in fevers, 
particularly those of childhood. The dose is J to 1 ounce (16.0-30.0) 
every few hours. 

Liquor Potassii Citratis, U. S., is made in the same manner as is 
the neutral mixture, except that citric acid is substituted for the 
lemon-juice (citric acid 6 Gm., potassium bicarbonate 8 Gm., and 
water 100 mils.). 

The neutral mixture is the better preparation of the two, but more 
expensive. A very refreshing and agreeable way of prescribing this 
drug is in the form of "effervescing draught," made by mixing two 
solutions which are prepared as follows: (1) Lemon-juice and water, 
equal parts, enough to make 4 ounces (120 mils.) (2) Bicarbonate of 
potassium 1 drachm (4.0) and water 3 ounces (90.0). These solutions 
are to be mixed in the quantities desired, and taken while effervescing. 
If lemon-juice is not at hand, a solution of citric acid of the strength 
of 2 drachms (8.0) to 4 ounces (120.0) of water should be employed 
in its stead. 

Under the name of Potassii Citras Effervescens the U. S. P. of 
1900 calls for an official powder possessing the advantages of the 
mixture just named. 

POTASSIUM CYANIDE. 

Cyanide of potassium (no longer official) is used in the same way 
and for the same purpose as hydrocyanic acid. (See Hydrocyanic 
Acid.) The dose is -^ to to grain (0.006). 

The following prescriptions may be used in cases suffering from 
bronchitis or phthisis accompanied with excessive cough: 

1^ — Potassii cyanidi gr. ij (0.12). 

Morphinse sulphatis gr. j (0.06). 

Syrupi pruni virginianse . q. s. ad f §iij (90.0). — M. 
S. — Teaspoonful (4.0) three to five times a day. 

Or as follows: 

1$ — Potassii cyanidi gr. ij (0.12). 

Ammonii chloridi 3ij (8.0). 

Elixiris calisayae . . . q. s. ad f§iij (90.0). — M. 
S. — Teaspoonful (4.0) three or four times a day. 



POTASSIUM HYDROXIDE. 

Potassium hydroxide (Potassii Hydroxidum; Potassa Caustica, B. P.) 
is a hard white solid, which readily deliquesces ; it possesses great caus- 
tic power, and has been used in medicine for the purpose of burning away 
grotvths or exuberant ulcers. In small cutaneous cancers it is applied 
to the spot for a minute or two after the protecting scab is removed. 
The parts are then poulticed for several days, when the slough comes 
away. A piece of the drug placed on the skin by means of a pair of 



PROCAINE. 455 

forceps will at once soften and burn the tissues for some distance. 
The surrounding skin should be protected by wax, suet, or oils, and a 
piece of adhesive plaster, with a hole for the growth, should first be 
applied to prevent action on the surrounding healthy tissues. The 
burn produced by caustic potash is very painful, and cauterization 
through its influence should not be practised if it can be avoided. 
When the caustic has acted sufficiently, it is to be washed off with 
vinegar or other dilute acid to neutralize it. It may be used in extract- 
ing a foreign body from under a nail by scraping the nail until it is 
very thin, then applying a 15 per cent, solution to the spot until the nail 
is soft, washing the part with water. The object can then be grasped 
with forceps. Vienna paste (Potassa cum Calce) is used for the same 
purpose as is caustic potash. 

POTASSIUM IODIDE. 

(See Iodide of Potassium.) 

POTASSIUM NITRATE. 

Nitre (Potassii Nitras, U. S. and B. P.), or saltpetre, occurs in 
long, needle-like crystals and has a sharp, saline taste. Sal prunella 
is saltpetre melted and run into moulds. 

Next to the cyanide and chlorate of potassium, this is the most 
poisonous of the potassium salts, and produces when taken in over- 
dose, violent gastro-enteritis. While it does not affect the blood, it 
is more irritant than the chlorate. 

Nitrate of potassium is rarely employed at present, and has been 
very properly put aside as inferior to the harmless vegetable potas- 
sium salts (the citrate, acetate, and bitartrate). If used in rheuma- 
tism, the dose should be 1 ounce (30.0) in a pint (480 Cc.) of barley- 
water or syrup of acacia and water, to be taken in divided doses 
of a tablespoonful every three hours. Nitrate-of-potassium papers 
(Charta Potassii Nitratis) are made by dipping unsized paper in a 
solution of the drug of the strength of 20 parts of the salt to 80 parts 
of distilled water. They are rolled into cigarettes and smoked by 
asthmatics, or burned in a pan and the fumes arising from them inhaled. 
Their efficacy may be increased in cases where the respiratory mucous 
membrane is irritable by dipping them in compound tincture of ben- 
zoin and exposing to the air long enough to dry. They should then 
be protected from the air until used. The paper used should be 
moderately thin bibulous paper. 

PROCAINE. 

Procaine, German name novocaine, is a synthetic chemical, being the 
hydrochloride of para-amino benzoyl diethylamino ethanol. It is a 
colorless crystalline substance, soluble in equal parts of water, and is 
not damaged by boiling. 



456 DRUGS. 

Physiological Action. — Procaine paralyzes peripheral sensory nerves 
as does cocaine, but is not so irritant, although its benumbing effects are 
as marked as that drug. Experiments on animals indicate that it is 
about one-seventh as toxic as cocaine and one-third as toxic as eucaine. 
Dropped into the eye it does not cause mydriasis. 

Therapeutics. — The sole use of procaine is to produce anaesthesia 
either by topical application, infiltration, or by spinal ansesthesia. 
(For method see Tropacocaine.) Many surgeons regard it as the 
anaesthetic of choice for these purposes. In the eye the strength of 
the solution varies from 1 to 10 per cent. For infiltration anaesthesia, 
where large areas are to be affected, a J of 1 per cent. (0.25) may 
be employed, and for intraspinal anaesthesia 2 to 3 mils, of a 5 per 
cent, solution is to be used, combined, as a rule, with adrenalin or the 
synthetic product, suprarenin. When used in the nose the solution is 
usually of the strength of 5 per cent., and when employed in the 
throat the solution may be 10 to 15 per cent. When used as an anaes- 
thetic to the gastric mucosa the dose is said to be from 2 to 7 grains 
(0.01-0.5). The best way to use it is in the tablets of procaine and 
sodium chloride, prepared by the manufacturers for the preparation 
of solutions. 

PROTARGOL. 

^ Protargol is a new silver preparation containing 8.3 per cent, of 
silver, and occurs as a yellowish powder readily dissolved in cold and 
hot water, forming a clear solution. It is employed in gonorrhoea and 
in gonorrhoea! conjunctivitis because it is destructive to the gonococcus. 
(See Conjunctivitis.) It is not precipitated on contact with albumin 
or alkalies, nor by dilute hydrochloric acid. It therefore has distinct 
advantages over nitrate of silver. A 1 to 5 per cent, solution of pro- 
targol is the strength ordinarily used in the treatment of gonorrhoea, 
and these solutions may also be employed in the eye. (See Conjunc- 
tivitis.) If used on a camel 's-hair brush or swab, the solution may be as 
strong as 5 per cent. ; but if the drug is used as a collyrium its strength 
should not exceed 1 : 400 or 1 : 200. 



PRUNUS VIRGINIANA. 

Prunus Virginiana, U. S., and Pruni Virginianoe Cortex, B. P.— 
wild cherry, as it is incorrectly called — is the bark of Prunus sero- 
tina, a large tree of the United States and Canada. It contains a 
substance known as amygdalin, which when it comes in contact with 
w T ater forms hydrocyanic acid through the action of another substance, 
known as emulsin. 

Therapeutics. — Wild-cherry bark is largely used as a domestic tonic, 
and in the form of a syrup as a vehicle for cough mixtures. 

It has been supposed that the hydrocyanic acid present allays the 



QUASSIA. 457 

cough, but this is doubtful, as the acid is fleeting in its effect and is 
present in very small quantity. 

Administration. — As a tonic prunus virginiana is used in the form 
of the infusion, dose J to 1 ounce (16.0-30.0), and the fluidextract, 
dose 30 minims to 1 drachm (2.0-4.0). The syrup (Syrupus Pruni 
Virginiance, U. S. and B. P.) is given in the dose of 1 to 4 drachms 
(4.0-16.0), i to 1 fluidrachm (2.0-4.0), B. P. The B. P. also contains 
a tincture (Tinctura Pruni Virginiance), given in the dose of J to 1 
drachm (2.0-4.0). 

PYOKTANIN. 

(See Methyl Blue.) 

PYROGALLOL. 

Pyrogallol, U. S., sometimes called pyrogallic acid, is a triatomic 
phenol obtained by carefully heating gallic acid, and should be kept 
in dark, well-stoppered bottles. It occurs in light white scales or 
crystals, has no odor, but a bitter taste. If exposed to the light, it 
becomes dark. It is soluble in 1.7 parts of water, 1.6 ether and 1.3 
alcohol. 

Therapeutics. — Pyrogallol is used in parasitic skin diseases, in oint- 
ment, in the strength of 30 to 100 grains (2.0-6.6) to the ounce (30.0). 
The stronger ointments exercise a mild caustic effect. It may be 
employed in place of chrysarobin in psoriasis. It stains the skin a 
deep brown. 

QUASSIA. 

Quassia, U. S. (Quassia* Lignum, B. P.), is the wood of Picrasma 
excelsa, a large tree of Jamaica and other islands of the West Indian 
group. It is also derived from Quassia amara. It contains an active 
principle, named quassin, which is intensely bitter and an irritant to 
mucous membranes. 

Quassia is a simple bitter tonic which has been used very largely in 
domestic medicine and by the medical profession. It is very efficient 
as a tonic, is supposed to be particularly useful in the anorexia 
following malarial fevers, and has even been thought to possess 
antiperiodic power. In simple dyspepsia with eructations after 
meals, due to gastric inactivity, it is very serviceable. 

In the treatment of seat-worms (Oxyuris vermicularis) , or thread- 
worms, as they are often called, injections of the infusion of quassia 
are the most efficacious and useful remedial measures we possess, and 
yet are harmless to the patient. The bowel should be well washed 
out with soap and water, and \ pint to 1 pint of an infusion, made 
by adding 1 to 2 ounces (30.0-60.0) of quassia chips to a pint (480) 
of water, should be injected and retained for some minutes. A few such 



458 DRUGS. 

injections will invariably kill the parasites, provided the bowel is first 
well washed out with soap and water and enough fluid is injected to 
reach high up into the rectum. 

Administration. — The tincture (Tinctura Quassia, U. S. and B. P.) 
is given in the dose of \ to 1 drachm (2.0-4.0), the fluidextract 
i drachm (2.0), and solid extract 1 to 3 grains (0.06-0.2). The 
infusion (bifusum Quassia, B. P.) is given in the dose of \ to 1 
ounce (16.0-30.0), and is made by macerating 10 grammes of 
quassia with 1000 mils, of water, and allowing it to stand fifteen 
minutes or more. 



QUERCUS. 

Quercus, or white oak, in infusion made from the crude drug 1 
ounce (30.0) to the pint (480 mils.), or by adding the fluidextract to 
water, is used as an astringent injection in gonorrhoea and vaginitis in 
women, where a large amount of fluid is necessarily employed. It 
is also used in prolapse of the rectum, in hemorrhoids, in leucor- 
rhcea, and as a gargle in sore throat. It stains the clothing very 
slightly. 

Quercus Tinctoria is equally efficient, but is seldom used because 
it stains the clothing. In the form of the powdered bark it is often 
used as an astringent poultice to freely running sores, to check the 
discharge. 

RESIN, OR ROSIN. 

Resina, U. S. and B. P., is resin or rosin, the mass left after the 
distillation of turpentine, and enters largely into plasters, cerates, and 
similar preparations. Its fumes when it is burnt are said to be of 
value when inhaled in cases of chronic bronchitis. Ceratum Resina, 
U. S., is used in chilblains and superficial scalds. Ceratum Resince 
Composition, U. S., popularly known as Deshler's Salve, is used as a 
stimulating application. Unguentum Resina is a B. P. preparation, 
and is used for the same purposes as the cerate. 

RESORCINOL. 

Resorcinol, U. S., and Resorcinum, B. P. (metadioxybenzol) , is the 
#? eta -compound of the group of which hydrochinone is the para- and 
pyrocatechin the ortho-, and occurs in clear crystals of a slightly 
reddish hue. It is quite soluble in water, alcohol, and ether. 

Physiological Action. — Resorcinol is an irritant to mucous mem- 
branes, and when taken internally in poisonous doses causes deafness, 
giddiness, salivation, profuse sweat, unconsciousness, and clonic con- 
vulsions. The heart of the dog under its influence is at first slowed 



RESORCINOL. 459 

by vagal stimulation, and then becomes very rapid in its action from 
vagal palsy. 

Therapeutics. — Resorcinol has been found of service as a remedy for 
whooping-cough, given in the dose of 10 minims (0.60) of a 2 per cent, 
solution or used in a spray of the same strength, the latter being the 
better method of using the drug. 

Resorcinol has also been employed in a spray in 2 per cent, solution 
in hay fever with remarkably good effects. It has been used as an 
antipyretic, but is not serviceable and has little power over fevers. 

The chief use of resorcinol is in skin affections of a subacute or 
chronic character, such as eczema with much induration, and in 
psoriasis. In these states an ointment of the following character, 
well applied, is of service : 

1$ — Resorcinolis 3j (4.0). 

Zinci oxidi 3j (4.0). 

Unguenti aquae rosae ox (40.0). — M. 

S. — Apply twice a day to the part affected. 
After mixing the ointment heat it until the resorcinol crystals melt, to prevent 
any irritation of the skin. 

Resorcinol is also of service in weak solution in allaying itching of 
the skin due to erythematous eczema. For this purpose it should be 
used in watery solutions of about 10 or 15 grains to the ounce, and a 
little salt added to aid in its absorption by the skin. This should be 
dabbed, not rubbed, on the part: 

Bf — Resorcinolis . . . gr. xv (1.0). 

Glycerini ripe (0 60). 

Liquoris calcis f 5j (30.0). — M. 

In the slowly spreading epithelioma of the face the following plaster, 
recommended by Hartzell, is useful: 

ly — Resorcinolis gr. lxxij (5.0). 

Cerae flavi et pulveris resinae . . . . 3iss (6.0). 
Olei olivae q. s. — M. 

Another valuable use of resorcinol is in the treatment of seborrhea 
capitis of the dry, scaly type : 

1$ — Resorcinolis 5j (4.0). 

Olei ricini nptxx (2.0). 

Alcoholis . . , f 5ij (60.0). 

Spiritus myrciae ... . . . q. s. f5iv (120.0). — M. 

S. — Use as a lotion to the scalp, after washing with castile soap and water. 
once a day. 

Within the last few years resorcinol has been employed with good 
results in the treatment of gastric ulcer in the dose of 2 to 4 grains 
(0.12-0.25) before each meal in pill or capsule. It is supposed to act 
by reason of its analgesic, antiseptic, and haemostatic power. 



RHAMNUS PURSHIANA. 

(See Cascara Sagrada.) 



V 

460 DRUGS. 

RHIGOLENE. 

Rhigolene is a product of petroleum obtained by repeated redistillation 
until the liquid resulting from this process boiis at 64.4° F. It evap- 
orates more rapidly than any other known liquid, except cymogene, 
which boils at 32° F., and is used in a spray for the production of 
localized numbness or freezing before minor painful operations, such 
as the use of the actual cautery. 

RHUBARB. 

Rheum, U. S. (Rhei Radix, B. P.), is the root of several species of 
Rheum, a plant of Thibet, but which is cultivated in America and 
elsewhere. It is also derived from China, and this variety is known as 
Chinese rhubarb. Several alkaloids are contained in it, all of which 
are unimportant and never used alone, except chrysophanic acid. 

Physiological Action. — According to the studies of Prevost and 
Binet, rhubarb acts inconstantly upon the flow of bile, sometimes 
increasing it, sometimes having no effect; but, on the other hand, 
according to those of Rutherford and Vignal, it never fails to stimu- 
late biliary secretion. Owing to the astringent properties possessed 
by rhubarb, it does not purge excessively, and improves the appetite, 
digestion, and intestinal tone. Its constant use produces chronic con- 
stipation. 

Therapeutics. — Whenever it is desired simply to unload the bowels 
without affecting the general system rhubarb may be employed. 
With equal parts of castor oil it is very effective. In children a state 
is very commonly seen in which constipation is replaced by diarrhoea if 
any ordinary laxative is employed, and in these instances rhubarb is 
the best remedy, as it is astringent and prevents any after-effects 
other than those directly produced by the dose. In the summer 
diarrhoea of children, when the stools are green, rhubarb is often used 
to empty the bowels of fermentative products before direct treatment 
is instituted. 

Rhubarb, because of its chrysophan, may stain alkaline urine car- 
mine or acid urine yellow. 

Administration. — The preparations of rhubarb are unnecessarily 
numerous. Rhubarb itself may be given in the dose of 20 grains 
(1.3) in powder, and small pieces of the root are habitually chewed 
by some persons for the relief of constipation. Extr actum Rhei, 
U. S. and B. P., is given in the dose of 5 to 10 grains (0.30-0.60) 
in pills. Piluloe Rhei, U. S., of which each pill contains 3 grains 
(0.20) of rhubarb, is given in the dose of one to three pills; and 
Pilul& Rhei Composite, U. S., and Composita, B. P., which con- 
tain 2 grains (0.12) of rhubarb and l\ (0.09) of aloes, are given in 
the same dose. Pulvis Rhei Compositus, U. S. and B. P., contains 
rhubarb, magnesium oxide, and ginger, and is given in the dose of 20 to 



ROCHELLE SALT. 461 

40 grains (1.3-2.6); Fluidextractum Rhei, U. S., is given in the dose of 
20 to 30 minims (1.3-2.0). Syrupus Rhei, U. S. and B. P., is given 
in the dose of 1 drachm (4.0) to a babe, and 4 drachms (16.0) to an 
adult, although rarely used for older persons. Syrupus Rhei Aro- 
maticus, U. S., is given in the same dose and to the same class of 
cases. Tinctura Rhei, U. S., is used in the dose of \ to 2 drachms 
(2.0-4.0), Tinctura Rhei Aromatica, U. S., Tinctura Rhei Composita, 
B. P., is used in the dose of J to 1 drachm (2.0-4.0), and Tinctura 
Rhei Dulcis, U. S., 2 to 3 drachms (8.0-12.0). The aromatic syrup 
is commonly employed for children, and the compound pills for adults. 
Infusum Rhei, B. P., is given in the dose of 1 to 2 ounces (30.0-60.0). 



RHUS AROMATICA. 

Sweet sumac is unofficial, but has been so largely used of late that 
it deserves notice. In hematuria, Menorrhagia, diabetes insipidus, 
and in urinary incontinence in children depending upon vesical atony 
t has been highly praised. In the latter affection a sufficient amount 
of experience has been acquired to show that it really is of benefit. 
Rhus aromatica should be used in the form of the fluidextract, derived 
from the bark of the roots according to the general directions in the 
Pharmacopoeia for making fluidextracts. The dose as a remedy for 
urinary incontinence is 15 minims (1.0) of this preparation. Adults 
may take from 15 to 60 minims (1.0-4.0). The drug is best given 
with glycerin and water. 



RHUS GLABRA. 

Rhus Glabra, smooth sumac, is the fruit of Rhus glabra, and con- 
tains tannic and malic acids as its chief constituents of medicinal 
value. In the fluidextract we have a preparation which is very 
efficient as a gargle for sore throat when diluted with glycerin and 
water or prepared according to the formula given under Potassium 
Chlorate. 

ROCHELLE SALT, 

Potassii et Sodii Tartras, U. S. (Soda Tartar ata, B. P.), is largely 
used as a saline cathartic in the dose of \ ounce (16.0), and is pre- 
ferred by many patients to Epsom salt because its taste is not so 
disagreeable. It is, however, more irritating. Rochelle salt is the 
purgative constituent of Seidlitz powder. 



462 DRUGS. 

ROSA GALLICA. 

Rosa Gallica, U. S. (Rosce Gallicce Petala, B. P.), red rose, con- 
tains gallic and tannic acids, and is astringent. From it are pre- 
pared the Fluidextractum Rosce, U. S., dose 5 drops to 2 drachms 
(0.30-8.0), used to flavor other extracts, and the Confectio Rosce, 
U. S., and Confectio Rosce Gallicce, B. P., which are used as bases for 
pills. Mel Rosce, U. S., or honey of rose, is employed as a local 
application or as a vehicle for gargles, and the Syrupus Rosce, U. S. 
and B. P., dose 1 to 2 drachms (4.0-8.0), as a flavoring substance. 
The acid infusion (Infusum Rosce Acidum, B. P.) is given in the dose 
of i to 1 fluidounce (15.0-30.0). 

Aqua Rosce, U. S. and B. P., is used as a diluent or solvent for 
preparations, such as astringents, which are to be employed locally, 
as in injections for gonorrhoea. It may also be used internally for 
these purposes. Unguentum Aquce Rosce, U. S. and B. P., is "cold 
cream, " and is largely used as an emollient application to small 
burns, sores, cuts, scratches, and chapped hands and lips It is much 
improved if a little glycerin and benzoic acid are added to keep it 
sweet in warm weather. 

RUBUS IDiEUS, OR RASPBERRY. 

Rubus Idceus, or raspberry, is used for the preparation of a syrup 
(Syrupus Rubi Idcei), which is employed very largely as an elegant 
vehicle or flavoring mixture. The leaves are often used in domestic 
medicine in a decoction or infusion for the cure of diarrhcea when an 
astringent is needed. 

RUE. 

Ruta graveolens is the source from which is derived the oil 
of rue. 

Physiological Action. — Locally applied, rue is an irritant, producing 
vesication, and if taken internally in large amount gastro-enteritis, 
which may be very severe. It is eliminated by the lungs, kidneys, 
and skin, and its odor is easily recognized in all these secretions. If the 
dose be poisonous, vomiting, great pain in the belly, and epileptiform 
convulsions come on, but death has rarely occurred. 

Therapeutics. — Rue has been used as an abortifacient, but with 
great danger to the mother. Its action is most uncertain even when 
poisonous doses are employed. It has been given in colic as a 
carminative, and seems to be valuable in atonic menorrhagia and 
metrorrhagia. 

Oil of rue has been employed for the removal of lumbricoid or round- 
worms, but ought not to be so used. The dose of the oil is 3 to 6 minims 
(0.20-0.40), best given in capsule.- 



SALICYLIC ACID. 463 

SACCHARIN. 

Saccharin (Benzosulpkinidum, U. S.; Glusidum, B. P.) is the anhy- 
dride of ortho-sulphamide-benzoic acid or benzoyl-sulphonic-imide. It 
occurs as a white, crystalline powder, nearly odorless, having an 
intensely sweet taste even in dilute solutions. It is soluble in 290 
parts of water and in 31 parts of alcohol, and but slightly soluble in 
ether or chloroform at 25° C. (77° F.); soluble in 25 parts of water at 
100° C. (212° F.). This compound was first prepared by Fahlberg, 
under the direction of Professor Remsen, of Johns Hopkins University. 
It is a remarkably sweet substance, two hundred and twenty times 
stronger than sugar in sweetening power. It is used largely to sweeten 
glucose and in confections. Saccharin escapes from the body un- 
changed, and is used in place of sugar to sweeten coffee, food, or 
medicine in cases of diabetes and gout. 

The dose is indefinite, but it is to be noted that a very few grains 
will sweeten a large bulk of material. As 1 grain (0.06) is equiva- 
lent to about 1 teaspoonful (4.0) of sugar, less than 1 grain is the 
quantity usually given. It is commonly sold in small tablets contain- 
ing half a grain each (0.03). 

Physiological Action. — Upon the circulation and similar vital func- 
tions saccharin has no effect, but Pliigge has proved it to retard the 
action of all the digestive ferments, and to be in consequence not 
devoid of evil effect on diabetics whose digestion is impaired. 



SALICIN. 

Salicin (Salicinum, U. S. and B. P.) is a glucoside obtained 
from several species of Salix and Populus. In other words, it is 
obtained from willow-bark. It is crystalline, without odor, and quite 
bitter, and is soluble in 23.5 parts of water and 88.5 of alcohol at 25° C. 
(77° F.). Salicin is highly thought of by many practitioners as a sub- 
stitute for salicylic acid in the treatment of acute articular and muscular 
rheumatism. It has also been largely used in the treatment of influenza. 
The dose is from 5 to 40 grains (0.3-2.6) every four hours, and it is 
best given in capsule or cachet, and washed down with a draught of 
water or milk after food has been taken. 

SALICYLIC ACID. 

Salicylic acid (Acidurn Salicylicum, U. S. and B. P.) occurs in 
fine white crystals or in fine white powder. It has a sweet yet acrid 
taste, and is derived from carbolic acid by treating it with caustic 
soda and carbonic acid at a moderate heat. Sometimes it is derived 
from plants in which it exists in combination, although the artificial 



464 DRUGS. 

acid is chiefly used. If the crystals are pinkish in hue, the acid should 
not be used, as it is probably impure. It is soluble in 460 parts of 
water and 2.7 parts of alcohol at 25° C. (77° F.). 

Physiological Action. — On mucous membranes salicylic acid acts as 
an irritant. (See Poisoning.) 

Nervous System. — Upon the nervous system salicylic acid exerts 
a moderate influence when given in medicinal doses, and causes 
buzzing in the ears and decrease of the reflexes. In poisonous doses 
epileptiform convulsions are produced by an action on the brain. 

Circulation. — Upon the circulation the effects of salicylic acid 
are not very marked in medicinal dose. It undoubtedly has a depress- 
ant rather than a stimulant effect, but the depression is very slight. 
It is sufficient, however, to make the use of the drug in cases of feeble 
circulation worthy of thought and care. 

Respiration. — Salicylic acid feebly stimulates the pulmonary vagi 
and respiratory centre, but if the dose be poisonous death is 
due to respiratory failure. Medicinally it does not affect this 
function. 

Temperature, — The effect of salicylic acid on temperature has 
been studied by the author with a good deal of care. The drug acts 
as a distinct antipyretic upon fevered states, and is a slight depressant 
of normal bodily heat. The studies of Gedl, Fiirbringer, and See 
also show this, and those of Danewsky point to it. In the experiments 
of North upon man, after and during exercise, the antipyretic effects 
were marked. According to the author's studies, the drug lowers 
fever by diminishing heat-production and increasing heat-dissipation, 
but this is by no means positively decided as a fact. 

Absorption and Elimination. — Salicylic acid is absorbed from 
the stomach as a salicylate of sodium, and so circulates in the blood. 
It is eliminated by the kidneys and by all the secretions. In the urine 
it appears as salicyluric acid. According to Kolbe, after a dose of 1 
ounce (30.0) elimination does not commence for three hours, but 
Fleischer found the drug in the urine in one and a half hours. Usually, 
however, it is far more rapidly eliminated, and, as pointed out by 
Soullier, after a dose of 15 grains (1.0) it appears in the urine in ten 
to twenty minutes and after 30 grains (2.0) in five minutes. The 
elimination continues for a period of from thirty-three to fifty-six hours 
(Weill). The urine after very large doses is dark olive green, and this 
change in color is due to the presence of indican and pyrocatechin, 
which are formed by the action of the pancreatic juices upon the drug 
in the intestine. The presence of salicyluric acid in the urine is to 
be discovered by the addition of a solution of the chloride of iron to 
that fluid, which causes the appearance of a violet color. Stockman 
has shown that salicyluric acid is inert, so the drug probably acts as 
salicylate of sodium. 

The increase in the elimination of uric acid when salicylic acid is 
given is not due so much to an increase in the excretion of acid already 



SALICYLIC ACID. 465 

formed, but is due to increased metabolism or tissue change produced 
by the drug. That the drug does not increase the elimination of the 
uric acid already deposited in the tissues is also proved by the fact that 
the salicylic acid and not salicyluric acid is often found in the kidney. 

Poisoning. — Salicylic acid when taken in excessive dose causes 
profuse sweating, roaring in the ears, dimness of vision, headache, 
partial or total deafness, and a decided fall in temperature. The 
pulse becomes weak and relaxed, and finally ptosis, strabismus, and 
general paralysis ensue. The urine and feces are passed i involun- 
tarily, and the urine is olive green in color. The respirations at first 
are quickened and deepened, but finally become shallow and feeble, 
death ensuing from respiratory failure. 

If the dose is sufficiently large, the blood is involved and the cor- 
puscles rapidly break down. 

Therapeutics. — Salicylic acid, owing to its close resemblanc to 
quinine, was first introduced as an antiperiodic and antipyretic, but 
soon was found to be of inferior value in these states and of super- 
lative value in acute articular rheumatism, in which disease it is 
supposed to destroy the specific-micro-organism. 

At present it is rarely if ever used for either of the former pur- 
poses, but is largely employed as a standard remedy for the latter 
disease. (See Rheumatism.) 

The value of salicylic acid in rheumatism limits itself solely to 
the relief of pain and the cure of the malady without preventing the 
complications incident to its course. That is to say, the changes in 
the joints or heart in rheumatism are only of less frequency after the 
use of salicylic acid because the drug shortens the disease, and not 
because it prevents these changes by a direct influence; this is also 
true of rheumatic hyperpyrexia, where salicylic acid is of service in 
shortening the attack, though it often fails to control the temperature 
to any great extent. In acute rheumatism 15 to 20 grains (1.0-1.3) 
should be given every four hours until marked physiological symptoms 
occur. With these doses it is wise to give 10 to 15 grains (0.60-1.0) 
of sodium bicarbonate to prevent irritation of the stomach and because 
clinical experience has shown that this combination acts better for 
the cure of the disease than the salicylates alone. When larger doses 
are used the sodium bicarbonate tends to prevent the development of 
coma associated with acetonuria. Another method is to give 30 or 
40 grains at 5 and 7 p. m., with a copious draught of milk, so that the 
main effects will be produced during sleep. It is to be remembered, 
however, that in many cases the salicylates seem to be of no value 
whatever, merely producing sweats and headaches, and it is also 
worthy of note that nothing else does these cases much good, as they 
seem bound to run a given course before the patient recovers. If a 
cure does take place, relapses are very common indeed, and the drug 
should always be continued for many days after all symptoms cease. 

When chorea is associated with rheumatism it is a better drug 
30 



466 DRUGS. 

than arsenic. In gonorrheal rheumatism salicylic acid is of no value, 
for it has no influence upon the gonococcus in the joints. In rheu- 
matoid arthritis it is valueless. 

The question as to the value of the salicylates in cases of gout is 
one open for debate. Some physicians regard it as useful, others 
as useless. Thus Duckworth states that in his experience and 
that of his friends the salicylates do not compare with colchicum. 
On the other hand, S£e, Jaccoud, and Haig find them useful. If 
they are of any value, it is only when the dose is very large, and even 
then their usefulness seems to be doubtful. In that systemic state 
sometimes called "lithpemic" the salicylates are useful. In subacute 
rheumatism citrate or acetate of potassium may be used in place of 
salicylic acid in the dose of 30 to 60 grains (2.0-4.0), these salts 
being taken just before going to bed. 

In lumbago, sciatica, and similar states salicylic acid is a very 
useful remedy. While it is not so good as phenacetin in neuralgia, it 
is of great service in the migraine of rheumatic persons, often curing 
the disease. (See article on Migraine.) 

Brunton has highly recommended the use of the salicylates with 
the bromidss in the nervous irritability of gouty or lithaemic persons. 

Salicylic acid has been largely used for the removal of pleural effu- 
sion if the effusion be serous. Dock believes that the duration of 
treatment is less with the salicylates than by the use of diuretics, 
alteratives, or purgatives, but the author has not reached good results 
from this plan of treatment. The dose should be from 1 to 2 drachms 
(4.0-8.0) daily. Doses larger than this are not necessary. How sali- 
cylic acid does good in pleural effusion is not known, as its diuretic 
properties are not sufficiently great to drain away the liquid by this 
means. 

In quinsy or true tonsillitis the drug is thought by some practitioners 
to act as a specific, particularly when this condition is associated with 
a rheumatic tendency or goutiness. It will often prevent suppuration, 
shorten the attack, and relieve the pain and swelling. The doses 
should be small, say 3 grains (0.20) at each dose, and given hourly. 
In stomatitis, after the blisters have broken, the burning and pain are 
often intense, and a mouth-wash of salicylic acid in the proportion of 
1 to 250 of water is useful. 

Ringer recommends the use of the following salve in pruritus of 
the anus and vulva: 

1^ — Acidi salicylici 5ij (8.0). 

Olei theobromatis ov (20.0). 

Cetacese 5iij (12.0). 

Olei myristicae f oiss (6.0). — M. 

In the treatment of corns there is probably no better application 
than lint soaked in a solution of salicylic acid, or the use of the follow- 
ing formula as a paint, which should be applied after sOaking the foot 
in hot water: 



SALICYLIC ACID. 467 

1$ — Acidi salicylici gr. xxx (2.0). 

Extracti cannabis indicse . . . gr. v (0.30). 

Collodii f oss (16.0).— M. 

S. — Apply with a brush until a good coat is formed. 

After a few days the corn can be peeled off with ease. 

A useful salve for the soreness following horseback or bicycle riding 
is one composed as follows: 

3— Acidi salicylici gr. x (0.60). 

Adipis benzoinati 5j (30.0). — M. 

S. — Apply to the sore part. 

A solution of salicylate of sodium or of bicarbonate of sodium, 
applied on lint to inflamed rheumatic joints, often gives great relief. 
Smearing an ointment of salicylic acid over the joints not only pro- 
duces good effects locally, but by absorption of the drug influences 
the disease. (See Rheumatism, Part IV.) 

In gastric dilatation or catarrh, where vomiting occurs and the 
matters vomited contain sarcince, salicylic acid will be found of ser- 
vice, as it acts as an antiseptic in the stomach. In adults suffering 
from ascaris lumbricoides, or round-worms, salicylic acid may be used 
in the dose of 8 grains (0.5) every hour till 40 grains (2.60) are taken, 
This treatment should be followed by the use of a purge. For thread- 
er seat-worms the following injection will be found of service: 

1$ — Acidi salicylici 5ss (2.0). 

Sodii boratis . oss (2.0). 

Aquae Oj (480).— M. 

S. — Warm, and inject into the bowels. For a child reduce this one-half in all 
its parts. 

In bromidrosis of the feet (excessive sweating with fetor) salicylic 
acid may be dusted over the parts, or the following powder used: 

Py — Acidi salicylici, 

PuTveris amyli aa oss (16.0). — M. 

S. — Apply to the feet. 

In eczema of the face and hands, where the eczema is of the wet or 
weeping variety, salicylic acid, locally applied, is often of great service. 

Py— Acidi salicylici gr. v yel x (0.3-0.60). 

PuTveris amyli 3ij (8.0). 

Pulveris zinci oxidi 5ij (8.0). 

Petrolati . . gss (16.0).— M. 

S. — Apply locally. 

If the eczematous process is subacute and needs stimulation, the 
salicylic acid may be increased to 20 or 30 grains (1.3-2.0). 

Antiseptic Use. — Salicylic acid is employed as an antiseptic in tne 
treatment of wounds as a local remedy and as a dressing, but should 
not be applied over too large an area, as it may be absorbed and pro- 
duce constitutional symptoms. As an application to small burns a 
mixture of 1 drachm (4.0) of salicylic acid to 8 ounces (240.0) of olive 
oil is of sendee. 



468 DRUGS. 

In the treatment of soft chancres and venereal sores salicylic acid 
has been largely used by some practitioners either as a salve or as a 
dusting-powder, as follows: 

I£ — Acidi salicylici gr. xx (1.3). 

Alcoholis gtt. xlv (3.0). 

Adipis benzoinati oij (60.0). — M. 



Or, 



1$ — Acidi salicylici gr. xv (1.0). 

Pulveris amyli vel cretse 3 i j (8.0). — M. 



Salicylic acid may be added to urine to prevent its decomposition, 
but will sometimes cause the reactions for sugar to appear. Patients 
taking salicylic acid often notice that the urine is odorless after stand- 
ing, and that it will remain fresh for many days because of the salicyluric 
acid present in it. The drug may cause, when taken internally, the 
reaction of sugar in the urine with Trommer's test. 

Untoward Effects. — Salicylic acid, as already stated, may produce 
headache and roaring sounds in the ears. In persons with middle-ear 
disease it is contraindicated unless urgently called for, as it often 
makes the deafness permanently worse. Sometimes erythema or 
acne follows its employment, and blindness and retinal hemorrhages 
have occurred. Strumpell asserts that delirium of an active character 
sometimes appears after full doses of salicylic acid, which delirium is 
usually happy in its type, and is seen most commonly in young girls. 
Sometimes full doses produce visions which may be seen only when 
the eyelids are closed. When very large doses are given symptoms 
resembling diabetic coma may develop and acetonuria may become 
marked. The use of chloroform for anaesthesia, when such doses of 
salicylic acid are being used, is probably more dangerous than usual. 
(See Chloroform.) It is impossible to enumerate all the untoward 
effects which have been noted, but it is worthy of remark that very 
few deaths have taken place. 1 Binz thinks that full doses of salicylic 
acid may produce abortion in women who already have a tendency 
to abort, and Vineberg thinks that menorrhagia and metrorrhagia 
are caused by it. 

Contraindications to the use of the salicylates are meningeal inflam- 
mation or congestion, middle-ear disease, albuminuria, inactivity of 
the kidneys, particularly that occurring in pregnancy, and Bright's 
disease. 

Administration. — Salicylic acid has a nauseous taste and is irritant 
to the stomach. It may be given in a solution of glycerin and compound 
tincture of cardamom or its taste may be masked by the use of syrup 
of bitter orange-peel or syrup of ginger. The following formulae may 
be used: 

1 See author's Boylston Prize Essay of Harvard University on Antipyretics. 



SALOL. 469 

1$ — Acidi salicylici 5ij (8.0). 

Tincturae lavandulse composite . . . f §vi (180.0). 

Glycerini f§ij (60.0). 

S. — A tablespoonful (16.0) every four hours. 

Salicylic acid is best given in capsule with a little sodium bicarbonate, 
but as it is irritant to the stomach in so concentrated a form, the 
capsule must be taken with water or milk, and should follow rathei 
than precede meals. 

If buzzing in the ears produced by this acid is annoying, bromide 
of sodium in the dose of 20 grains (1.3) will generally give relief. 

Salicylic-acid ointment (Unguentum Acidi Salicylici, B. P.) is a 
useful preparation for external application in chronic, deep-seated 
skin diseases. 

SALICYLATE OF ETHYL. 

Ethyl salicylate, sometimes called "Sal Ethyl" (JEthylis Salicylas), 
has the same action as the other salicylates, but is said to be less prone 
to produce disagreeable effects. It occurs as a colorless, volatile 
liquid, of pleasant aromatic taste, and is given in capsules in the dose 
of 5-10 minims (0.3-0.6 mil.), as may be indicated. 



SALICYLATE OF METHYL. 

(See Gatjltheria.) 

SALICYLATE OF SODIUM. 

Salicylate of sodium (Sodii Salicylas, U. S. and B. P.) is a less 
irritant and somewhat less disagreeable preparation than salicylic acid. 
Its internal action, use, and doses are the same as those of the acid. 
It may be given by dissolving it in milk, and then adding rennet to 
produce a curd, which disguises the taste and protects the stomach. 
It is very soluble in water. 

Other salicylates are largely used by some practitioners. Salicylate 
of lithium is supposed by some physicians to be of more value than 
the other salts. (See Aspirin, Strontium, and Salophen.) 

SALOL. 

Phenylis Salicylas, U. S., Salol, B. P., is a white crystalline powder, 
faintly aromatic and almost without taste. It is not soluble in water, 
but is in alcohol, and an alcoholic solution forms an imperfect emulsion 
when mixed with water. Salol is also slightly soluble in copaiba, in the 
oils of sandal-wood and of turpentine, and in mineral oils. This solu- 



470 DRUGS. 

bility is very useful in prescribing it with these remedies in certain 
diseases of the genitourinary apparatus. (See Gonorrhoea.) 

Salol is a compound of 60 parts of salicylic acid and 40 of phenol, 
and is decomposed by the pancreatic juice into these two substances. 
For this reason overdoses are capable of producing symptoms of phenol 
poisoning. Thus 20 grains of salol (1.3) taken five times a day will 
cause a person to take 40 grains (2.60) of phenol, which is almost a 
poisonous dose. 

Hesselbach has proved that large doses of salol are very apt to 
affect the kidneys unfavorably, and rightly believes it to be contra- 
indicated in all cases of renal inflammation of an acute type. 

It is worthy of note that the drug rarely produces untoward effects, 
although at one time a number of observers accused it of frequently 
doing so. 

Salol is used for the same purposes as salicylic acid in the treat- 
ment of rheumatism when the stomach is so irritated that it cannot 
bear the latter drug, as salol is dissolved in the small intestine. A dose 
often used is 5 grains (0.30) an hour, but this is too much, as a rule, 
and may produce renal irritation. Salol is also useful in muscular 
rheumatism and neuralgia due to exposure. In pharyngitis 5 grains 
(0.30) of salol, given three times daily, is a valuable part of the treat- 
ment of the affection, and in persons subject to chronic sore throat 
due to the lithaemic diathesis this treatment will often produce 
extraordinary results. It is of the greatest use in duodenal catarrh 
and catarrhal jaundice to arrest intestinal fermentation. 

In the treatment of gonorrhoea in all its stages salol may be employed 
by the mouth, as in its elimination it sterilizes the urine and tends 
to disinfect or sterilize the urethra at each act of micturition. (See 
Gonorrhoea.) 

Salol is of great value in intestinal indigestion and fermentation, 
and is sometimes used in cases of mild or pernicious anaemia when 
it is thought that the development of decomposition products is their 
cause. (See Anaemia.) In diarrhea dependent upon such causes salol 
is one of the best remedies we have, since it renders the intestinal 
canal antiseptic, and so removes the cause of the disorder, instead of 
locking the putrid material in the bowel, as does opium. In cholera 
morbus the following is very useful: 

1$ — Phenylis salicylatis 3j (4.0). 

Bismuthi subnitratis 3ij (8.0). 

Misturse cretse q. s. ad f §iij (90.0). — M. 

S. — Two teaspoonfuls (8.0) every two hours. "Shake" well. 

Wide experience with the drug in the treatment of cholera during 
epidemics has proved it to be one of the best remedies that can be 
employed in the treatment of this disease. 

Salol may be given in wafers, capsules; or pills, in the dose of 5 
grains (0.3) or more. 



STEAROSAN. 471 



SALOPHEN. 



Salophen (Salophenum) has been introduced as a substitute for 
salol, and is said to possess the advantage of being far less poisonous 
than salol, because in this case the phenol of the salol is replaced by a 
compound of phenol, which is innocuous. Experiments on animals 
seem to indicate that these theoretical advantages are present in fact. 
Salophen is broken up in the intestine by the juices there present, 
and the result is salicylic acid and acetylparamidophenol. Salophen 
contains about 10 per cent, less salicylic acid than does salol (51 per 
cent.). 

Therapeutics. — For the therapeutics of salophen the reader is referred 
to the article on Salol, as the indications for both drugs are identical, 
save that salophen can probably be used when salol cannot be em- 
ployed. The dose of salophen is from 5 to 20 grains (0.3-1.3) three 
times a day. It can be very effectually combined with acetphenetidin 
in the treatment of neuralgia. In subacute rheumatic affections it is 
certainly very useful. 

SALVARSAN. 1 

(See Arsphenamine.) 



SANDAL-WOOD OIL. 

Sandal-wood oil (Oleum Santali, U. S. and B. P.) is derived from 
the wood of Santalum album, sl tree of India, and has a hot, burning 
taste. In overdose the oil is capable of producing great irritation of 
the genito-urinary passages. 

Therapeutics. — The oil of sandal-wood is much used by genito- 
urinary surgeons in chronic gonorrhoea and gleet, and in chronic cystitis. 

In the subacute stages of bronchitis, when the expectoration is thick 
and ropy, the oil is efficacious. In the excessive cough following influ- 
enza it is of great value. In all cases it should be given in capsule in 
the dose of 5 to 20 minims (0.3-1.3), 5 minims (0.3) being usually 
sufficient, although druggists generally keep it in 10-minim (0.6) 
capsules. 

STEAROSAN. 

Under the name Stearosan a product is on the market which 
dissolves only in the intestine and so can be used when ordinary oil of 
sandal-wood irritates the stomach. It is given in capsules of 10 
minims (0.65). 

1 By using the American name both during and after the war, physicians will avoid 
employing a German-made product and so directly rewarding the holders of German 
patented articles. 



472 DRUGS. 

SANGUINARIA. 

Sanguinaria, U. S., or blood-root, is the rhizome of Sanguinaria 
canadensis, and has been largely used in medicine, but is a dangerous 
remedy, possessing more power for harm than good. Its chief alkaloid 
is sanguinarine. 

Poisoning. — Sanguinarine in poisonous dose causes vomiting, purg- 
ing, profuse salivation, and finally tonic convulsions which are spinal 
in origin. Death is due to respiratory failure, but the circulation is 
much decreased in force and frequency. 

Therapeutics. — The employment of sanguinaria in chronic bronchitis 
is about the only purpose for which it is now employed to any extent. 
As an emetic in croup it has been largely used, but is too irritating and 
depressing, and ought not be so employed. According to Bartholow, 
the drug acts as an hepatic stimulant, and is of service in gastro-intestinal 
catarrh and jaundice. 

Administration. — The dose of the fluidextract is 1 to 5 minims (0.06- 
0.30) as an expectorant, or 10 to 30 minims (0.60-2.0) as an emetic. 
If the drug does not cause vomiting after an emetic dose, it must not 
be allowed to remain in the stomach, as it is poisonous. The tincture 
(Tinctura Sanguinaria, U. S.) is the best preparation to use, and may 
be given in 20- to 30-minim (1.30-2.0) doses as an expectorant, and 
1 to 3 drachms (4.0-12.0) as an emetic. The vinegar (Acetum Sangui- 
naria?) is no longer official, but is given in the dose of 10 to 30 minims 
(0.60-2.0), and as an emetic in the dose of 2 to 4 drachms (8.0-16.0). 

SANTONIN. 

Santoninum, U. S. and B. P., is a neutral principle derived from 
Levant Worm-seed or Santonica, which is the unexpanded flower- 
heads of Artemisia pauciflora (Maritima, B. P.), a plant of Asia 
Minor and Turkestan. Santonin is soluble in alcohol and chloro- 
form, but slightly so in water. Santoninic acid is formed by warming 
santonin with alkalies, and Hesse has found that santonin is an anhy- 
dride of santoninic acid. Santoninic acid is more soluble than santonin. 

Poisoning. — Santonin causes, when taken in overdose, muscular 
tremors, convulsive movements, unconsciousness, and sometimes epi- 
leptiform convulsions. 

One of the most common symptoms of the poisoning is chroma- 
topsia or xanthopsia, during the existence of which all objects look 
yellow. This is due to the staining of the humors of the eye by the 
drug. This may go. on to total blindness or pass away in a few days. 
If the vision is not yellow, it may be green. The urine is also stained — 
first yellow, then saffron, and finally purple red, or is bloody looking. 
This is not due to the presence of blood, but to the drug. Poisonous 
doses of the drug do not cause gastro-enteritis. 

Therapeutics. — Santonin is used for the removal of the round-worm. 



SARSAPARILLA. 473 

and is very efficacious. It has no influence on the tape-worm. It 
should be given in the manner of all vermifuges (see Worms) — namely, 
at a time when the alimentary canal is empty. Santonin is said to 
have a distinct influence over vision, increasing, in medicinal amount, 
its acuity whenever the optic nerve is at fault. In urinary incontinence 
santonin will often produce a cure after all other remedies fail. 

Santonin may be given in the dose of 1 to 2 grains (0.06-0.12) 
to an adult in capsule or wafer. The crystals should be used, not 
the powdered santonin. Immediately after the drug is used, a 2- 
or 3-grain (0.12-0.2) dose of calomel is to be taken, and followed 
by a saline purge six hours later, as the flow of bile caused by the 
mercurial is particularly useful in making the worm let go its hold. 

Santoninate of sodium (Sodii Santoninas) is a useless, harmful 
preparation, never to be employed except for the benefit of the eye 
when vision fails through disease of the optic nerve. Introduced 
into medicine because of its solubility, it is absorbed into the system, 
which is just what is least desired in an anthelmintic, which should 
seek the worm in the bowel, not by entering the blood. In eye affec- 
tions the dose may be from 2 to 8 grains (0.12-0.50) a day, accord- 
ing to the age of the adult. 

Untoward Effects. — In addition to the curious effects already named 
santonin may cause urinary incontinence even in medicinal dose. 

Administration. — Santonin is best given in the form of a troche or 
lozenge (Trochisci Santonini, B. P.), 1 grain (0.06) each, but it is to 
be distinctly borne in mind that the Trochisci Sodii Santoninatis 
of the U. S. P. of 1880 are not to be sold to the patient. A useful 
recipe is as follows : 

ty— Santonini gr. v (0.3). 

Pulveris sacchari albse 5iij (12.0). 

Pulveris acaciae gr. viij (0.5). 

Misce bene, et adde 

Mucilaginis acaciae gtt. xvj (1.0). 

Aquae q. s. 

Ft. in troches No. x. 

S. — One or two lozenges, as directed. 



SARSAPARILLA. 

Sarsaparilla, U. S., is the root of Smilax medica, Smilax ornata, 
and other species of Smilax, growing chiefly in Central America. 
The drug is devoid of any marked physiological action, yet seems 
to possess some power over the general condition of the system. 
Thus while sarsaparilla seems utterly without effect in the hands of 
most physicians when given alone, it often seems to do good and to 
increase the effects of other drugs when combined with them, so that 
some cases of syphilis which are of an obstinate character are said to 
yield to iodide of potassium and sarsaparilla when the iodide alone 
fails. Sarsaparilla is largely used in domestic medicine as a "blood- 



474 DRUGS. 

purifier," and is a prominent constituent of many patent medicines. 
It is useless for such purposes and is a much overrated remedy. 

Administration. — Sarsaparilla is most commonly given in the form 
of the compound syrup (Syrupus Sarsaparilla Compositus, U. S.), 
composed of sarsaparilla, sassafras, liquorice, gaultheria, anise, and 
senna, dose 1 to 4 fluidrachms (4.0-16.0). (See Iodide of Potassium.) 
The other official preparations of the U. S. P. are the compound fluid- 
extract (Fluidextractum Sarsaparilla? Composition), similar to the 
syrup in composition, dose J to 1 fluidrachm (2.0-4.0); and the 
fluidextract (Fluidextractum Sarsaparilla 3 ) , dose ^ to 1 fluidrachm 
(2.0-4.0). The B. P. preparation is a liquid extract (Extractum 
Sarsce Liquidum), dose § to 4 fluidrachms (2.0-16.0); and Liquor 
Sarsce Compositus Concentratus, dose 2 to 8 drachms (8.0-30.0). 

SAVINE. 

Sabina is the tops of Juniper us sabina, an evergreen shrub of 
Northern Europe, Asia, and America. It contains a volatile oil. 
Locally applied, this oil is more of a counterirritant than is turpentine, 
and if swallowed in poisonous amount causes nausea, vomiting, gastro- 
enteritis, unconsciousness, suppression of urine and death. If the 
individual be a pregnant female, abortion takes place as death 
approaches, but very rarely before this time. Profuse flooding nearly 
always accompanies the abortion and the drug cannot be used to 
empty the uterus without great danger. 

Therapeutics.— The oil, taken in the dose of 5 to 10 minims (0.30- 
0.60), repeated every three or four hours, acts as a powerful stimulant 
to the uterus and ovaries, causing hyperemia and aiding in the pro- 
duction of menstruation in cases of amenorrhcea. It may also be 
employed with advantage in some cases of menorrhagia. The drug is 
best given in emulsion or capsule. The fluidextract is given in the 
dose of 5 to 15 minims (0.30-1.0). 

SCAMMONY. 

Scammonice Radix, B. P., is a mixture of gum-resins from the root 
of Orizaba Jalapa, growing in Asia Minor and Syria. Its active 
principle is sometimes called jalapin. 

Therapeutics. — Scammony is an irritant, drastic, hydragogue purge, 
which causes a good deal of griping and exerts a cholagogue effect. 
If an inflammatory condition of the bowels is present, its use is contra- 
indicated. 

The ingestion of poisonous doses is to be followed by treatment 
suitable for gastro-enteritis. Scammony is given in the dose of 2 to 5 
grains (0.12-0.30), always in combination with some other similar 
drug— as, for example, colocynth. Scammony forms part of the com- 
pound extract of colocynth (Extractum Colocynthidis Compositum, 



SCOP AM US AND SPARTEINE. 475 

U. S. and B. P.), the dose of which is 1 to 3 grains (0.06-0.19) as a 
laxative, 5 to 20 grains (0.3-1.3) as a purge; 2 to 8 grains (0.13-0.52) 
B. P. The resin (Resina Scammonits, U. S.; Scammonice Resinoe, B. P.) 
is given in the dose of 3 to 8 grains (0.19-0.52). The B. P. preparations 
of scammony are Pilula Scammonii Composita, dose, 5 grains (0.3), 
and Pulvis Scammonii Compcsitus, dose, 10 to 20 grains (0.65-1.3). 
The last two preparations are composed of scammony, ginger, and 
jalap. 

SCARLET RED. 

Medicinal scarlet red occurs as a dark reddish-brown powder which 
is insoluble in water and but slightly so in cold alcohol, acetone, ether, 
and benzene. It is, however, soluble in chloroform and very soluble 
in fats and oils, and slightly soluble in petroleum and paraffin. For 
these reasons lard should be used as the ointment base, not petrolatum. 
Its chemical name is amido-azo-toluene-azo-beta-naphthol. 

Therapeutics. — Scarlet red is used to stimulate the growth of epi- 
thelium over clean granulating surfaces. If the part affected is very 
acutely inflamed, it must be used with caution. After it has been 
applied in ointment for twenty-four to forty-eight hours it should be 
followed by a soothing salve, as of pure lanolin. After the part is 
cleansed with warm water and soap, scarlet red can be applied to bed- 
sores, leg ulcers, slowly healing burns, and on clean venereal and syphilitic 
ulcers in ointment form of 2 to 8 per cent, strength. If the ulcer is 
very large the ointment should be applied only around the edges. It 
is not antiseptic in its action. The 10 per cent, ointment commonly 
found in the market, diluted one-half with liquid albolene, is a useful 
application in ozcsna after the crusts are removed with peroxide of 
hydrogen. It has also been used to aid in the healing of perforation 
of the tympanic membrane. In the latter cases the treatment must be 
stopped every few days to avoid excessive stimulation and irritation. 

SCOPARIUS AND SPARTEINE. 

Scoparins (Scopari Cacumina, B. P.), or broom, is the tops of 
Cystisus scoparins. It contains scoparin and sparteine, the first 
being a crystalline principle and the second a liquid alkaloid. The 
second (sparteine) is the alkaloid used in medicine in the form of 
a sulphate (Sparteines Sulphas, U. S.), which is a crystalline salt readily 
soluble in water. 

Physiological Action. — As scoparius depends for its medicinal value 
almost entirely upon sparteine, what is here said applies to both the 
crude drug and the alkaloid. 

Nervous System. — Sparteine acts on the nervous system very 
decidedly if given in toxic doses, depressing the brain and spinal cord, 
chiefly in the motor tracts of the latter, thereby causing a decrease of 
reflex action and motor power, ending in complete paralysis. These 
changes occur both in man and in the lower animals. 



476 DRUGS. 

Circulation. — Upon the circulation sparteine acts as a stimulant. 
It quickens the pulse-rate in moderate doses, and also raises arterial 
pressure. The force of the contraction of the ventricles is also in- 
creased. In large poisonous doses the drug acts as a circulatory 
depressant. 

Respiration. — Upon this function sparteine, in small amounts, has 
no effect, but poisonous doses kill by paralysis of the respiratory centre. 

Kidneys. — There is little evidence to prove that sparteine acts 
directly on the kidneys. MacNider believes from his investigations 
that when diuresis is produced by its use the increased flow is due to a 
rise in blood-pressure. 

Poisoning. — The symptoms of poisoning consist in trembling and 
inco-ordination of movement, and clonic and tonic convulsions, fol- 
lowed by a second stage of depression of the nervous system and 
general enfeeblement. 

Therapeutics. — Sparteine sulphate. has been recommended in all states 
of the heart in which digitalis is of service, and it is sometimes useful 
in those fairly frequent cases where digitalis fails. In cardiac arrhythmia 
or palpitation it is thought to be of great service by those who have 
used it most. Clark found it of value in Graves' disease and in nearly 
every circulatory abnormality, but in the judgment of the author 
sparteine is not a very useful drug — one only to be turned to as a 
last resource after more generally used remedies fail; or, in other words, 
it is not a remedy to be employed as a "stand-by" in the manner in 
which digitalis is used. 

In the few cases in which it has been used by the writer it failed to 
be of service, perhaps because the cases were desperate and the drug 
was tried after all the other remedies had failed. The dose is as variable 
as its action. Some state it to be 2V grain (0.003), while still others 
recommend 2 to 4 grains (0.12-0.25). The latter dose is more nearly 
the correct one. To get the best effects it should be given every two 
hours in the dose of \ grain. The drug should be given in watery solu- 
tion or in pill. 

One or 2 grains (0.06-0.12) given hypodermically are useful for 
suppression of urine after operations. 

Potts claims to have found sparteine of value in the treatment of 
tremor, as in paralysis agitans, in the dose of \ to i grain (0.015- 
0.03) three times a day. 

Scoparius itself is used in decoction, made by adding \ ounce (16.0) 
of the broom-tops to a pint (480) of water, and boiling them down to 
a \ pint (240). Of this an ounce should be taken every three hours. 
This decoction is one of the most efficient diuretics in cardiac dropsy. 
The official preparations of the B. P. are an infusion (Infusum Scoparii), 
and the juice (Succus Scoparii), dose 1 to 2 drachms (4.0-8.0). 



SCOPOLAMINE. 477 

SCOPOLAMINE. 

Scopolamine, or hyoscine, is an alkaloid derived from the dried 
rhizome of Scopola Carniolica, a plant of southern Europe, yielding 
not less than 0.5 per cent, of mydriatic alkaloids, which possesses 
medicinal powers closely resembling those of belladonna and its sister 
drugs. Its physiological action is particularly closely allied to that of 
the alkaloids of hyoscyamus. As stated in the article on Hyoscine, 
it has been introduced in its stead. The terms hyoscine and scopol- 
amine are used interchangeably. (See Hyoscine.) 

Hyoscine itself is rarely employed, the hydrobromide (Scopolamines 
Hydrobromidum, U. S.) being preferable. It also occurs as the 
hydriodide and hydrochloride. 

Scopolamine administered hypodermically with morphine has been 
largely used by some surgeons for the production of general anaesthesia, 
the condition being produced by the administration of these drugs at 
intervals of from one to three hours for two to four doses preceding the 
time of operation. In most cases one or two doses only are employed 
to cause primary stupor, which is then maintained by the adminis- 
tration of ether or chloroform. The dose of scopolamine used for 
anaesthesia has usually been t ^-q grain (0.0006), combined with y^ 
grain (0.005) of morphine sulphate, at each injection. The so-called 
" scopolamine-morphine method," when used to supplant ether and 
chloroform, has not proved popular, and experience seems to indicate 
that it is by no means devoid of danger, but used beforehand it allays 
fear, lessens the amount of anaesthetic needed, decreases post-anaes- 
thetic vomiting, and causes the patient to sleep for several hours after 
the operation. (See also Hyoscine and Morphine.) 

Scopolamine and morphine have also been used together to relieve 
the pains of labor. Scopolamine, tto grain (0.00043), and f grain 
(0.01) of morphine sulphate are injected hypodermically when the pains 
are occurring about every four or five minutes and lasting for thirty 
seconds. Great care must be exercised in determining that the labor 
has actually begun. Such a dose usually acts in about half an hour, caus- 
ing sleep between the pains. If this is not sufficient to markedly relieve 
pain, the dose of scopolamine, without the morphine, is repeated. 
The patient should be protected from noise and bustle after the dose is 
given. If memory is preserved after this second dose, the same dose of 
scopolamine is again given. This treatment is said to cause a painless 
labor devoid of accident to mother, and although the groaning of the 
woman may indicate pain, she usually states afterward that she has 
not suffered. It is probably not as safe for the child, and all are 
agreed that the patient must be so carefully watched that it should 
be used with care and only in a lying-in institution. 



478 DRUGS. 

SEIDLITZ POWDER. 

Under the official name of Pulvis Efjervescens Compositus the U. S. P. 
recognizes a purgative powder (Pulvis Soda? Tartar atoe Effervescens, 
B. P.) made by taking the bitartrate of sodium and potassium, or 
Rochelle salt 120 grains, and bicarbonate of sodium 40 grains, which 
are wrapped in blue paper, and 35 grains of taratric acid placed in a 
white paper. The contents of each paper are dissolved in water — 
half a tumblerful — and the two solutions added to one another and 
swallowed during effervescence. As much as two powders may be 
used, but this is generally too large an amount unless full purgation 
is needed. In sick stomach associated with constipation, when a whole 
powder cannot be retained, the two powders should be divided into 
fourths, and a fourth added to a fourth dissolved in a half-wineglassful 
of water and taken every fifteen minutes until the entire powder is 
ingested. This will often settle the stomach and produce purgation. 

SENEGA. 

Senega, U. S. (Senegce Radix, B. P.), is the root of Polygala senega, 
a small plant of the United States, containing a principle known as 
polygalic acid and senegin. 

Therapeutics. — Senega is used in medicine as a stimulating expec- 
torant in the subacute and chronic forms of bronchitis. It has also 
been employed as a diuretic in cardiac dropsy or that due to renal 
disease. In cardiac disease it should not be used, and indeed it is 
rarely employed at present except in combination with other drugs in 
expectorant mixtures. 

Administration. — Senega is used in the form of the fluidextract 
(Fluidextractum Senega;, U. S.), dose 10 to 20 minims (0.60-1.3) and 
the syrup (Syrupus Senegas, U. S.), dose 1 to 2 drachms (4.0-8.0). It 
is also used in Coxe's Hive Syrup. The official preparations of the 
B. P. are — a tincture (Tinctura Senegas), dose 1 to 2 drachms (4.0-8.0), 
and an infusion (Infusum Senegas), dose 1 to 2 ounces (30.0-60.0). 

SENNA. 

Senna, U. S., is the most drastic of the laxative purges used for the 
relief of constipation. It is the leaflets of Cassia acutifolia and Cassia 
angustifolia, and contains a very acrid irritant purgative principle 
known as cathartic acid. Senna is official in the B. P. as Senna Indica 
and Alexandrina. 

Physiological Action. — Senna acts as a purge, producing copious 
stools, often with much griping if it is used alone. According to 
Rutherford and Vignal, it materially increases the flow of bile, but 
it is seldom, if ever, used in medicine as a cholagogue, although, 






SENNA. 479 

according to Prevost and Binet, cathartic acid has an influence over 
biliary secretion. Hess has found that the drug acts directly as a 
stimulant upon the mucous membranes, and so produces a local 
peristalsis as it is moved along. It is also known that the drug is 
eliminated in the milk, and for this reason care should be taken in 
giving the drug to nursing mothers, as it will purge the nursling. 

Administration. — Senna is generally combined with other drugs for 
the relief of constipation, but may be used alone. If this is done, 
the fluidextract (Fluidextr actum Sennas, U. S.) may be employed in 
the dose of 1 to 2 drachms (4.0-8.0) to a child or 4 drachms (16.0) 
to an adult. It is, however, always better to give children the more 
agreeable confection (Confectio Senna?, U. S. and B. P.) in the dose of 
J drachm (2.0) to a child, or 1 to 2 drachms (4.0-8.0) to an adult. As the 
confection is apt to cause gastric disorder if used continuously because 
of the sugar contained in it, its use is limited to a small class of cases. 

In the treatment of the constipation of pregnancy senna is thought 
to be very useful. In these cases and in others w T here cascara sagrada 
alone will not move the bowels, senna may be prescribed as follows: 

1$ — Fluidextracti sennae f5ij (60.0). 

Fluidextracti cascarae sagrada? .... fgj (30.0). — M. 
S. — Teaspoonful (4.0) at night, or night and morning. 

Should this produce griping J to 1 minim (0.025-0.05) of fluidextract 
of belladonna may be added to each dose. Under the name of Black 
Draught a mixture of senna, manna, fennel, and sulphate of magnesium 
has been largely used (Infusum Senna? Composition, U. S.) in the dose 
of 4 ounces (120.0). It is an active hydragogue purge. The syrup 
(Syrupus Sennee, U. S. and B. P.) is given in the dose of 1 to 4 drachms 
(4.0-16.0). 

One of the best ways to use senna is in the compound liquorice 
powder (Pulvis Glycyrrhizas Compositus, U. S. and B. P.), which is a 
good laxative in the dose of 20 to 30 grains (1.3-2.0), 1 to 2 drachms 
(4.0-8.0), B. P. Compound liquorice powder is composed of senna, 
liquorice, oil of fennel, washed sulphur, and sugar. 

Infusum Senna?, B. P., is given in the dose of 1 to 2 ounces (30.0- 
60.0); Mistura Sennee Composita, B. P., in the dose of 1 to 2 ounces 
(30.0-60.0); and Tinctura Senna? Composita, B. P., in the dose of 
1 to 4 drachms (4.0-16.0). Liquor Sennee Concentratus, B. P., is given 
in the dose of 1 drachm (4.0). 

Senna, because of its chrysophan, may stain the urine carmine if 
that fluid is alkaline, or yellow if it is acid. No alarm should be felt 
if either color appears in this secretion. Often it is necessary to warn 
the parents of a child of the possibility of such an occurrem e, in order 
to prevent alarm on the part of the mother, who otherwise might 
think that hematuria was present. 



480 DRUGS. 

SERPENTARIA. 

Serpentaria, U. S. (Serpentaria? Rhizoma, B. P.), or Virginia snake- 
root, is the rhizome and rootlets of Aristolochia serpentaria and Aristo- 
lochia reticulata, plants of the Southern United States. It contains an 
active principle, aristolochin, which is never used in medicine. 

Therapeutics. — Owing to the rather pleasant, warm taste of ser- 
pentaria, and the fact that it stimulates secretion, it is used largely as 
a vehicle for other more potent remedies. It has tonic properties, 
and in consequence has been largely used in the treatment of atonic 
dyspepsia and indigestion. It is said to be a sexual stimulant, but 
this is doubtful, to say the least. In overdose it is an irritant, and 
will cause vomiting and purging if large amounts are taken. 

Administration. — Serpentaria is given in the form of the fluidextract 
in the dose of 10 to 40 minims (0.6-2.6). It also enters into Huxham's 
Tincture of Cinchona (Tinctura Cinchona? Composita, U. S. and B. P.). 
Infusum Serpentarice, B. P., is given in the dose of J to 1 ounce (15.0- 
30.0). 

SILICATE OF POTASSIUM OR SODIUM. 

Soluble glass, or silicate of potassium or sodium, occurs as -a clear, 
syrupy fluid. It is used as a splint in the dressing of fractures and 
sprains, as it rapidly becomes hard and immovable when painted over 
the bandages. Silicate of potassium or sodium may be universally 
substituted for plaster of Paris. The solution of silicate of sodium is 
no longer official. 

SILVOL. 

Physical Properties. — Silvol appears in the form of black lustrous 
granules, slightly hygroscopic and hence very readily soluble in water. 
Solutions can be very quickly made, even having a concentration as 
high as 50 per cent, by weight. Ordinary solutions containing 2 per 
cent, or more of silvol are a brownish-black color, but when quite 
dilute this solution has a characteristic brownish-yellow tint. The 
substance is readily soluble in water and insoluble in acetone, alcohol, 
ether, chloroform, oils, and fats. 

Pharmacological tests upon animals would seem to indicate that 
silvol can be defined as practically " non-toxic." 

Silvol is now available in the form of one-ounce vials of the granu- 
lar powder; also in capsules, each of which contains 6 grains. 
These latter are specially prepared for the making of solutions, it 
being only necessary to empty the contents of one, two or more cap- 
sules in a measured quantity of water to produce a solution of such 
concentration as the physician may require. It also appears as 
silvol ointment containing 5 per cent, of the medicament. 

Bearing in mind that this product is intended to altogether displace 
solutions of silver nitrate, the therapeutic indications are evident. 



SOAP. 481 

Injections of 10 to 20 per cent, solution, three or four times per day 
may be used in gonorrhoea. A twenty-five per cent, solution is used 
in ophthalmia neonatorum and in purulent ophthalmia. 



SOAP. 

Sapo, U. S. (Sapo Durus, B. P.), is prepared from sodium hydroxide 
and olive oil, although other alkalies and oils may be employed in 
the manufacture of the soaps which are used medicinally. Castile 
soap, if good, is the best representative of a pure soap. 

Soap may be cut into the form of a suppository and used to pro- 
voke movements of the bowel in young children who are suffering 
from constipation, by placing it just inside the anus, having previously 
dipped it into water an instant to make it slippery. It may also be 
used as an enema, dissolved in warm water, or a mixture known in 
Philadelphia as the "House Mixture" may be employed in the case of 
an adult. This consists of a mixture of water, soft soap, and molasses 
in varying proportions, and if flatulence is present turpentine and olive 
oil are added to it. The preparation is as efficient as it is cheap and 
d.rty. Soap is also used as an antidote to many poisons and as an aid 
to emetics. 

Soft soap (Sapo Mollis, U. S. and B. P.), often called green soap, is 
usually brown. It is a soft soap made by the use of potash and 
linseed oil, and is largely used by dermatologists in the treatment of 
eczema and similar skin diseases where a detergent, stimulating 
application is needed. It is sometimes called "German soft soap," to 
distinguish it from the ordinary soft soap of the United States, which 
is an impure substance often made of rancid fats, containing a large 
excess of alkali, and never used except for scouring purposes. Green 
soap is employed not only as green soap, but also in the liniment 
(Linimentum Saponis Mollis, U. S.), which is to be thoroughly rubbed 
into the part when used medicinally, well washed off, and afterward 
simple cerate or some other soothing salve applied. 

Soap liniment (Linimentum Saponis, U. S. and B. P.), or opo- 
deldoc, as it is called in domestic medicine, is largely used for rubbing 
stiff muscles and sprains. It is generally employed to carry more active 
external remedies, such as opium or aconite. 

1$ — Tincturse aconiti, 

Tincturse belladonnse, 

Tincturse opii aa f 3ij (8.0). 

Linimenti saponis . . . . q. s. ad f§vj (180.0). — M. 

Soap plaster (Emplastrum Saponis, U. S. and B. P.) is used as a 
thick, heavy protective for bed-sores or where the formation of bed-sores 
is feared. It is also used as a support about sprained joints. 

31 



482 DRUGS. 



SODIO-SALICYLATE OF THEOBROMINE. 

Theobromine Sodiosalicylas, U. S., known as diuretin (Theobrominoe 
et Sodii Salicylas, B. P.), derives its name from the extraordinary 
power which it is said to possess of producing a great increase in the 
urinary flow from the kidneys. This power depends entirely upon the 
theobromine, which is a crystallizable, volatile, bitter alkaloid, closely 
allied to caffeine and xanthine, and derived from the seeds of Theobroma 
cacao, or the source of ordinary chocolate. Owing to the insolubility 
of theobromine, it has been found necessary to combine it with sodium 
salicylate, as under these conditions it is readily absorbed. 

The diuretic properties of this alkaloid were first discovered during 
a series of experiments made by Schroder, in Strasburg, in 1889, who 
found that the diuresis produced in man and the lower animals was 
marked. Many clinical trials in Europe and America have confirmed 
his observations, but there are a number of cases in which it signally 
fails, particularly in chronic Bright's disease. 

Theobromine does not have so stimulating an effect on the heart as 
does its relative caffeine, so that the circulatory effect, while showing 
a stimulant rather than a depressing tendency, is very slight. It 
slightly increases muscular power, but its peculiar affinity for the renal 
structure surpasses all its other activities. 

As the action of the drug depends upon its ability to stimulate the 
secreting epithelium of the kidney, the physician should remember 
that in cases of advanced renal disease, where the secreting structures 
are almost entirely destroyed, no result can be expected from its 
administration; but it is probable that the drug is useful in almost 
all conditions of dropsy, whether due to renal inactivity or cardiac 
disease, and is harmless to the patient even if the diuretic effect does 
not ensue. The only contraindication to the use of theobromine or 
diuretin is the presence of acute nephritis, when, of course, sedatives 
rather than stimulants are needed. So far as the writer is aware, no 
study as to the proportion of solids and liquids in the urine of patients 
under the influence of this drug have been made, but the fact that it 
stimulates the epithelium or secreting structures of the kidney would 
indicate that the solids are increased. 

As diuretin contains only from 30 to 50 per cent, of theobromine, 
it has to be given in very large amounts, as much as 1 to 2 drachms 
(4.0-8.0) in twenty-four hours, preferably in divided doses of from 
10 to 20 grains (0.60-1.3) in capsule or in warm water. The former 
method is the better, as the taste of the drug is disagreeable and soapy. 
Diuretin must not be exposed to the air, as it undergoes decomposition 

In all the cases in which the writer has tried sodio-salicylate of theo- 
bromine he has failed to see any effect produced, and, while he has no 
confidence in the drug, he mentions it because others claim to have 
obtained good results from its use. 



SODIUM. 483 



SODIUM. 



Sodium is a metallic element, the salts of which are usually white 
and colorless. It is not used in medicine, but many of its salts are 
employed. While potassium acts as a depressant to the body, sodium 
seems to exert comparatively little effect upon the animal economy. 
The salts vary in their power with the acid forming them. (See Ben- 
zoate of Sodium, Salicylate of Sodium, etc.) 

Acetate of sodium (Sodii Acetas, U. S.) is rarely if ever used in 
medicine as a substitute for acetate of potassium. The dose is 20 to 
40 grains (1.3-2.60) three times a day. 

Sodium Bicarbonate. 

Bicarbonate of sodium (Sodii Bicarbonas, U. S. and B. P.) is largely 
used as an antacid in gastric fermentation and in sick headaches arising 
from this condition. Combined with calomel in powder, it certainly 
adds to its efficiency in increasing biliary flow, as all alkalies of this 
class liquefy and thin the bile. The drug has been widely employed 
in the treatment of rheumatism, and is found to be of great service 
in allaying pain and soreness in the joints when used in a lotion made 
by dissolving it in water and applying it to the part on lint or rags. 
In acidity of the stomach the following effervescing powder is useful: 
Bicarbonate of sodium (Sodii Bicarbonas), 30 grains (2.0) in one paper, 
and in the other 5 grains (0.3) of tartaric acid (Acidum Tartaricum). 
These are each dissolved in half a tumbler of water, added to one 
another, and swallowed during effervescence. 

Sodium Cacodylate. 

Sodii Cacodylas, U. S., is a white amorphous powder which readi^ 
dissolves in water. Its uses in medicine are practically identical with 
those of arsenic. (See Arsenic and Arsphenamine.) It is less poisonous 
only because the compound is so stable that arsenic is slowly set free. 
The drug is best administered hypodermically. The dose is 1 to 2 
grains (0.06-0.12) subcutaneously, and 2 to 4 grains (0.12-0.25) by the 
mouth. In these doses given, as a rule, every other day it is a very 
efficient remedy in primary and secondary an&mia. Its use by the 
stomach causes not only a strong, garlicky odor on the breath, but also 
gastric irritation, because it is decomposed in this viscus. 

Murphy advised the intramuscular injection every third or fourth 
day of 1 to 4 grains (0.05-0.2) in syphilis, and stated that it destroys 
the spirochete of this disease, but this is doubtful. The large and 
small doses are now ready for use in solution in ampoules, and these 
should always be used. 



484 DRUGS. 



Sodium Chloride. 



Chloride of sodium (Sodii Chloridum, U. S. and B. P.), or common 
salt, is a useful drug and food, aiding in maintaining the alkalinity 
of the blood and tissues and in the formation of gastric juice, being 
changed by the lactic acid of the stomach into lactate of sodium, 
thereby setting free hydrochloric acid, which acts not only by aiding 
digestion, but in the production of pepsin from pepsinogen of the 
gastric tubules. The dose is 10 to 20 grains (0.60-1.3). 

It is official under the name Liquor Sodii Physiologicus, U. S., or 
normal salt solution. 

Sodium Citrate. 

• Sodium citrate (Sodii Citras, U. S.) may be used as a substitute for 
citrate of potassium but is less active. It has been highly recommended 
to aid in the digestion of milk by bottle-fed babies in that it prevents 
the formation of tough curds. When it is used it is not necessary to 
largely dilute cows' milk with water for these patients. The dose 
should be about 1 to 2 grains (0.05-0.1) to the ounce (30.0) of milk. 
It also tends to prevent infantile scurvy. The same drug may be used 
with advantage in cases of difficult milk digestion in adults suffering 
from gastric nicer, gastritis, and typhoid fever. (See Buttermilk in Part 
III, Foods for the Sick.) It is also used to prevent coagulation of 
blood in the practice of indirect blood transfusion. A 2 per cent, 
solution is prepared and used in such a proportion that the amount 
of sodium citrate in the injected blood does not exceed 0.2 per cent. 
(See Transfusion, Part III.) 

Sodium Ethylate. 

Sodium ethylate is a whitish powder decomposed in the presence 
of water into alcohol and caustic soda, but soluble in absolute alcohol 
without decomposition. 

Sodium ethylate is employed in medicine as a depilatory — that is, 
for the purpose of removing hairy growths. To accomplish this purpose 
it is necessary that the growth be dipped close to the skin, and that 
the drug be dissolved in absolute alcohol and applied over the roots 
of the hair with a glass rod. Soon after this application a crust forms, 
which should not be detached for two or three weeks, but which, in 
its removal at the end of this time, generally shows that all the roots 
of the hair have been destroyed. If not, the operation may be repeated 
as soon as the skin is in a condition to bear it. To prevent pain, a 5 
per cent, solution of cocaine may be used hypodermically at the spot 
to be cauterized. It is worthy of remembrance that moles and small 
birthmarks, or nsevi, may be removed by a similar application. Small 
scars may result. 

A solution, Liquor Sodii Ethylatis, is official in the B. P. 



SODIUM. 485 

Sodium Hydroxide. 

Sodium hydroxide (Sodii Hydroxidum, U. S., Soda Canstiea, B. P.) 
is milder than caustic potash, and its action is more readily controlled. 
It should be used in the same way and for the same purpose as is caus- 
tic potash, and the surrounding skin ought to be protected by adhe- 
sive plaster and oil or ointment. 

The soda must be kept in well-stoppered bottles made of hard, 
strong glass. The only official preparation in the U. S. P. is the 5 per 
cent, solution of sodium hydroxide, Liquor Sodii Hydroxidi. 

Sodium Phosphate. 

Sodii PJwsphas, U. S. and B. P., is a preparation which has been 
used with the idea that it can supplant phosphorus. This is, of course, 
an error, as it has an entirely different effect. It is particularly useful 
for bottle-fed children, who continually alternate between diarrhoea 
and constipation, and is also useful in cases of rickets to regulate the 
bowels. It should be added to each bottle of milk in the dose of 2 to 
4 grains (0.12-0.25). Phosphate of sodium in small doses is slightly 
laxative, and large doses are purgative. Bartholow believed phosphate 
of sodium to be the best remedy in hepatic cirrhosis and jaundice. 
To adults it should be given in the dose of 20 grains to 2 drachms 
(1.3-8.0) once, twice, or thrice a day according to the laxative effect 
desired. It is best given dissolved in a teacupful of hot water. 

Many cases of general wretchedness or headache due to autointoxi- 
cation are relieved by the acid phosphate of sodium. 

The U. S. P. and B. P. also recognize a preparation called Sodii 
Phosphas Effervescens; dose 2 to 4 drachms (8.0-16.0). Sodii Phos- 
phas Exsiccatus (U. S.) is about twice the strength of the ordinary 
phosphate; dose h to 1 drachm (2.0-4.0). 

(For an explanation of the purgative action of most salines see 
article on Magnesium Sulphate.) 

Sodium Acid Phosphate. 

Sodii Phosphas Acidus, B. P., or Sodium Acid Phosphate (NaH 2 P0 4 - 
H 2 0), or monosodium phosphate, differs from ordinary sodium phos- 
phate, which is disodium or neutral sodium phosphate (N^HPO^ILO). 
When taken into the stomach it is not changed, but in the intestine it 
is converted into disodium phosphate and acts in a similar manner as 
a mild purge. The neutralization of the acid takes alkali from the 
blood, and as the system guards the normal alkalinity of the blood with 
the greatest care there is a prompt excretion of acid in the urine to main- 
tain the normal balance. This makes an acid urine, which is desirable 
when it is alkaline and loaded with phosphates. It is also desirable 
when the colon bacillus infects the urinary tract, and it is desired to 
get the effect of hexamethylenamine which gives off its formaldehyde 



486 DRUGS. 

only in an acid urine. It is wise, therefore, to precede each dose of 
hexamethylenamine by some hours by a dose of 15 to 20 grains (1.0- 
1.3) of acid sodium phosphate. It maybe given dissolved in sweet- 
ened water so as to taste like lemonade. 

Sodium Sulphate. 

Sodii Sulphas, U. S. and B. P., or Glauber's Salt, is one of the irri- 
tant saline purges, rarely used in medicine by itself for human beings, 
but largely employed by veterinarians. The purgative dose for man 
is \ to 1 ounce (16.0-30.0). If any intestinal inflammation is present, 
it is contraindicated. It produces large watery stools, with a good 
deal of griping. Sulphate of sodium is a prominent constituent of 
Carlsbad water, Hunyadi Janos, Hunyadi Arpad, and similar waters. 
(For an explanation of the action of salines in producing purgation, 
see Magnesium Sulphate.) 

Reverdin has recently claimed that small doses of 2 grains (0.12) of 
sulphate of sodium every hour are of great value in controlling capil- 
lary hemorrhages and lor graver hemorrhages. It must be given by 
the mouth or intravenously. If given hypodermically he asserts it is 
useless. 

Under the name Sodii Sulphas Ejjervescens the B. P. recognizes an 
effervescent preparation of sodium sulphate, given in the dose of 2 
to 4 drachms (8.0-16.0). 

Sodium Sulphocarbolate. 
(See Phenolsulphonates.) 

Sodium Thiosulphate. 

Thiosulphate of sodium (Sodii Thiosulphas, U. S.) or hyposulphite 
of sodium, occurs in large, transparent, colorless plates which effloresce 
when exposed to the air. It has a slight alkaline reaction, and is 
soluble in about equal parts of water, but insoluble in alcohol. 

Therapeutics, — Thiosulphate of sodium is used in the proportion 
of 1 drachm (4.0) to the ounce (30.0) of water or lard in the treatment 
of parasitic skin diseases, particularly those due to the tricophyton 
fungus, such as pityriasis versicolor. It is also efficacious, locally 
applied, in rhus poisoning, and in cases of pruritus due to other 
causes, in the strength of \ drachm (2.0) to the ounce (30.0) of water. 
In malarial hematuria sodium thiosulphate is often given with 
advantage in the dose of from 10 to 30 grains (0.60-2.0) every four 
hours. How it acts in this condition is not known. 

Thiosulphate of sodium is largely used as a food preservative and 
in the amounts usually employed is harmless. 



SOZOIODOL. 487 

SOLANUM CAROLINENSE. 

Solarium carolinense, or horse nettle, is a low perennial plant of 
the natural order Solanaceoe, a native of the Southeastern United States. 

According to studies made by Thornton, the drug depresses the 
cerebrum, but excites the spinal cord. It has been introduced into 
medicine for the purpose of relieving epilepsy, particularly when the 
disease occurs in childhood. In a limited employment of the drug 
the author has found it serviceable in diminishing the frequency and 
severity of the attacks. The beginning dose of the fluidextract is 15 
to 60 minims (1.0-4.0) three times a day, but it may be increased to 
as much as 2 drachms (8.0) at a dose with advantage. 

SOMNAL. 

Somnal is stated to be ethylated chloral urethane, and seems to 
possess marked hypnotic power. It is a clear, colorless liquid, possess- 
ing a hot, burning taste 3 resembling that of sweet spirit of nitre. The 
dose is 20 to 40 minims (1.3-2.6) in liquorice-water or syrup of rasp- 
berry. The sleep produced by it is said to last seven to eight hours. 
In a number of cases in which the writer has used it, it acted satisfactorily 
although drowsiness was usually present the next day. 



SOZOIODOL. 

Sozoiodol is an antiseptic preparation first made and employed by 
one of our own countrymen in San Francisco, but at that time the 
preparation of it was so imperfectly carried out that foreign matters 
made it too irritating for general use. If was therefore discarded, 
only to be better prepared and more widely used in Germany some 
years later. 

Therapeutics. — Sozoiodol has been found of value as an antiseptic 
and disinfectant in the treatment of wounds which are in an unhealthy 
state, and for acute stomatitis and pharyngeal catarrh it may be em- 
ployed locally in the form of a 5 per cent, watery solution. It has 
also been found useful in acute purulent conjunctivitis and in oph- 
thalmia neonatorum, in the proportion of 2 parts of sozoiodol to 30 
parts of water. In urethritis of a specific type the preparation known 
as zinc-sozoiodol may be employed in a 2 per cent, solution with 
advantage, and this compound is also of value in mild and malignant 
vaginitis if preceded by pyroligneous acetic acid or nitrate of silver, 
applied by means of a speculum. 

In the treatment of catarrh of the cervix uteri, Nitschman uses 
sozoiodol in the form of a powder applied by means of a tampon with 
good results, and it would seem to be worthy of trial in many other 
states of the mucous membranes than those named. 



488 DRUGS. 

SPIGELIA. 

Spigelia, U. S., pinkroot, is the root and rhizome of Spigelia mari- 
landica, or Carolina pink, a plant of the Southern United States. 

Poisoning. — The symptoms of poisoning by spigelia closely resemble 
those of belladonna poisoning. 

Therapeutics. — Spigelia is one of the most efficient remedies in the 
removal of round-worms, and is not dangerous when given with 
care. When employed for the removal of worms, the usual precaution 
should be taken in regard to the ingestion of food (see article on 
Worms), and the drug should be followed by a purge to sweep out 
the worm while it is narcotized. The purge should be one which is 
rapid in its action, such as the sulphate of magnesium. 

Administration. — The dose of spigelia in the form of the fluidextract 
(Fluidextr actum Spigelian, U. S.) is 2 drachms (8.0); that of the un- 
official fluidextract of spigelia and senna (Fluidextr actum Spigelian 
el Senna?) is \ to 1 drachm (2.0-4.0) for a child of two years of age; 
i ounce (16.0) is the dose for an adult. The addition of fluidextract 
of senna makes the drug more efficient, and the mixture is generally 
not disliked by children. It is to be remembered that this latter 
mixture is no longer official. 

SQUILL. 

Scilla, U. S. and B. P., is the sliced bulb of Urginea maritima (Scilla, 
B. P.), a plant of the countries bordering on the Mediterranean. It 
contains scillin, scillipicrin, and scillitoxin, all of which possess poison- 
ous properties, and none of which is used in medicine alone, except 
by few practitioners. 

Poisoning. — In poisonous doses squill produces vomiting, purging, 
dulness, stupor, intermittent palsy, convulsions, and death in ten to 
twenty hours. These symptoms are preceded by a marked fall in tem- 
perature. The urine is suppressed or bloody and acute nephritis is 
produced. Gastro-enteritis may be marked. 

Physiological Action. — Squill possesses a physiological effect upon the 
heart closely allied to that of digitalis, and is thought by some to be 
capable of stimulating the heart muscle more powerfully than digitalis. 
Like digitalis, it is capable in overdose of inducing cardiac arrhythmia 
and even heart block. (See Digitalis.) 

It increases diuresis not only by raising blood-pressure in the kidney, 
as does digitalis, but by stimulating the secreting epithelium as well. 
In overdose it is a renal irritant. 

Therapeutics. — Squill is largely used as a stimulant or irritant diuretic, 
to affect the renal epithelium directly and promote secretion, and to 
tone up and excite to normal effort a kidney depressed by disease, 
as in chronic Bright's disease or renal congestion from cardiac trouble. 
In cardiac dropsy, when combined with digitalis, squill is a standard and 



SQUILL. 489 

much-used remedy, and is undoubtedly of value in aiding in the 
absorption of effusions in the pericardium, pleura, and abdomen. (See 
Digitalis.) Squill is usually given in dropsy, in pill form, as follows: 

1$ — Pulveris scillae gr. x (0.60). 

Pulveris digitalis foliorum gr. xx (1.3). — M. 

Fiant pilulae No. x. 

S. — One t. i. d. after meals. 

The employment of squill in bronchitis, although largely resorted 
to, is not to be commended, since its irritant action on the kidneys 
and stomach may cause trouble. The period for its administration is 
in the beginning of the second stage, when secretion is scanty or so 
excessive as to need proper stimulation of the mucous membranes 
to bring on a healthy action. At one time Coxe's Hive Syrup was 
largely used, either as an emetic in drachm doses every ten minutes 
until it acted, or as an expectorant in the dose of 30 minims to 1 
drachm (2.0-4.0) three times a day for an adult. As it contains 
antimony, it should be given with care. 

Squill may be used as a substitute for digitalis when the latter 
remedy fails in cases of ruptured compensation associated with val- 
vular disease. If after the use of squill for some days the urine 
diminishes in amount, the drug must be stopped, as this condition 
indicates spasm of the renal vessels or acute irritation. 

Administration. — The fluidextract (Fluidextr -actum Scillce, U. S.) is 
much used in the dose of 1 to 5 drops (0.06-0.3); the tincture {Tinc- 
ture Scillce, U. S. and B. P.) in the dose of 5 to 30 minims (0.30-2.0); 
the vinegar of squill (Acetum Scillce, U. S. and B. P.) in the dose of 
10 minims to \ drachm (0.60-2.0). The B. P. dose is 5-15 minims 
(0.03-1.0). The compound syrup (Syrupus Scilla 3 Compositus, U. S.), 
or Coxe's Hive Syrup, is composed of the fluidextract of squill, fluid- 
extract of' senega, tartrate of antimony and potassium, purified talc, 
sugar, and water, and is given in the dose of 20 minims (1.3) as a 
sedative to an adult and 1 drachm (4.0) as an emetic to a child. 

The following prescription will be found useful in bronchitis in its 
subacute stages in a child of one to five years: 

1$ — Villi ipecacuanha? f 3j (4.0). 

Tincturae scillae f 5j (4.0). 

Syrupi tolutani f^v(20.0). 

Aquae f 5J (30.0).— M. 

S. — Teaspoonful (4.0) every three or four hours. 

The plain syrup (Syrupus Scillw, U. S. and B. P.) is given in the 
dose of \ to 1 drachm (2.0-4.0), the honey (Oxymel Scilla, B. P.) 
in the dose of J to 1 drachm (2.0-4.0), and the compound pill (Pilules 
Scilla? Composita, B. P.) in the dose of 5 to 10 grains (0.3-0.60). 



490 DRUGS. 

STARCH. 

Amylum, U. S. and B. P., is corn starch, that is the starch grains 
of Zea mays. In very fine powder starch is used as a dusting-powder 
in intertrigo or chafing. Its more important uses are, however, in 
the form of starch-water for carrying drugs into the rectum, and in the 
form of a poultice for cases of skin diseases where it is desired to 
remove crusts. 

Starch-water is made by adding 2 tablespoonfuls of starch to 1 
pint of water, then boiling it to a paste and diluting it by the addition 
of warm water to the consistence of syrup. Starch-water is not only 
useful as a vehicle for drugs given by the rectum, but also as a sedative 
injection in proctitis and rectal irritation. 

The starch poultice is made by boiling the starch to a pasty con- 
sistence or by adding enough boiling water to a paste made by rubbing 
cold water and starch together to produce a gelatinous mass. Thirty 
grains (2.0) of boric acid to the ounce (30.0) render it antiseptic. 

STILLINGIA. 

Stillingia, U. S., queen's root, is the root of Stillingia sylvatica> 
a plant of the United States, the active principle of which is stillingin. 

Physiological Action. — There can be no doubt that this drug acts 
in two ways: first, by its immediate effects on the system, and, second, 
by its more slowly shown alterative influences. In overdose it causes 
bilious purging, increased heart action, and active secretion from the 
bronchial mucous membrane. 

Therapeutics. — Stillingia is highly recommended in habitual con- 
stipation, as it increases intestinal secretion, and it is even said to act 
as a specific in hemorrhoids dependent largely for their existence upon 
hepatic engorgement and intestinal atony. 

Bartholow recommended the following prescription under these cir- 
cumstances : 

I$— Fluidextracti stillingiae f 3v (20.0). 

Tincturse belladonnse foliorum, 
Tincturae nucis vomicae, 

Tincturse physostigmatis . aa f3j (4.0). — M. 

S. — 20 drops (1.3) in water t. i. d. before meals. 

Tincture of aloes may also be added to this prescription if constipa- 
tion is present. In syphilis of a severe type stillingia should be used 
as an aid to other drugs. 

In pasty-looking, white, " putty-faced" children, who are anaemic 
or strumous, and who never have any appetite, or are subject to 
middle-ear trouble and general debility, stillingia is of value. Under 
these circumstances it may be used for some time. 

The only official preparation is the fluidextract {Fluidextr actum 
Stillingia", U. S.), which should always be made of the fresh root, 
the dose of which is 10 to 60 minims (0.60-4.0). 



STRAMONIUM. 491 

STOVAINE. 

Stovaine is a synthetic substance used for the purpose of producing 
local anaesthesia. Technically speaking it is the hydrochloride of 
alpha-dimethylainine-beta-benzoylpentonal. In other words, it has 
a chemical composition closely allied to that of the other drugs which 
cause local anaesthesia. 

Stovaine appears in small, brilliant scales and is very soluble in 
water, methyl alcohol, and acetic ether. An important characteristic 
of stovaine is that it is not decomposed by boiling its solutions. 

The toxicity of stovaine when absorbed into the general system is 
said to be one-half that of cocaine. Instead of constricting blood- 
vessels in the area to which it is applied, it dilates them, and for this 
reason hemorrhage is more profuse in the wounded area when it is 
used than when cocaine is applied. When used for its anaesthetic 
effect in the eye, stovaine should be dissolved in normal salt solution 
in the strength of from 1 to 4 per cent. The 1 per cent, solution is 
used for subconjunctival injections and the 4 per cent, solution for 
instillations. For local anaesthesia by Schleich's method a solution of 
0.7 per cent, is used. The drug can also be employed for spinal anaes- 
thesia — 15 minims (1 mil.) of normal salt solution containing 1 grain 
(0.06) of the drug are injected. As a rule, however, it is best to use a 
fluid with a heavy specific gravity in order to limit the effect of the drug 
to the region in which it is injected, as, for example: stovaine, 1 grain; 
glucose, 1 grain; and sterile water, 20 minims (1.3). (For method, see 
Tropacocaine.) It is hardly necessary to state that this solution must 
be sterilized by boiling before it is injected. Untoward effects follow- 
ing this use of stovaine are said to be rarely met with, but when they 
have developed they have consisted in profuse sweating, vomiting, 
headache, and, in a few instances, relaxation of the sphincters. (See 
Cocaine and Tropacocaine.) Spinal anaesthesia is not as safe as anaes- 
thesia produced by the careful use of ether or chloroform. 

STRAMONIUM. 

Jamestown weed, or Datura stramonium, is official in the form of 
the leaves (Stramonium, U. S.; Stramonii Folia, B. P.), yielding, when 
assayed by the U. S. P. process, not less than 0.25 per cent, of mydri- 
atic alkaloids. It contains an alkaloid, known as daturine, which is 
physiologically identical with atropine. 

Physiological Action. — (See Belladonna.) 

Therapeutics. — The uses of stramonium are identical with those of 
belladonna. Stramonium leaves in the proportion of 8 ounces (250.0) 
to 2 ounces of nitrate of potash (60.0) afford, when this mixture is 
burned, an efficacious method of ridding a room of mosquitoes. 

Administration. — The extract (Extractum Stramonii, U. S. and B. 
P.), containing about 1.0 per cent, of alkaloids, is used in the dose 



492 DRUGS. 

of J to \ grain (0.001-0.03); and the tincture (Tinctura Siramonii, 
U. S. and B. P.), containing about 0.025 Gm. of total alkaloids in 100 
mils, in the dose of 5 to 30 minims (0.3-2.0). The ointment ( Unguen- 
tum Stramonii, U. S.) is also used for the same purposes as is belladonna 
ointment. The dose of daturine is t^-q to §V grain (0.0005-0.0008). 



STRONTIUM. 

This metal has been introduced into medicine in the form of the 
bromide (Strontii Bromidum, U. S. and B. P.), the iodide (Strontii 
Iodidum, U. S.) the salicylate (Strontii Salicylas, U. S.), and as the 
lactate and phosphate, largely through the studies of Laborde, See, 
Paul, and others. Bromide of strontium is used for precisely the 
same effects as are the other bromides, but it is claimed that, as the 
strontium is not irritating or depressing, the disadvantages of the 
potassium salt are avoided by its employment. The dose of bromide 
of strontium is from 30 to 60 grains (2.0-4.0). In addition to the 
ordinary effect of bromides, See found the bromide of strontium to be 
useful in overcoming attacks of gastric indigestion associated with pain 
in the stomach and hyperacidity; and the author has confirmed this 
statement. The lactate of strontium seems to be indicated chiefly in 
cases of albuminuria due to renal atony. It does not increase urinary 
flow, and is said to be contraindicated in the presence of uraemia and 
the high fever of acute parenchymatous nephritis. In chronic inter- 
stitial nephritis, such as is due to rheumatism or gout, it is said to be 
of value. Unfortunately, as soon as the lactate of strontium is with- 
drawn the albuminuria is apt to recur. The writer has often been 
much disappointed in the use of the lactate of strontium in albumin- 
uria, but others of wide experience seem to regard it as constant in 
producing good results. The dose of the lactate of strontium is 60 
to 100 grains (4.0-6.6) a day. 

The salicylate of strontium is a valuable preparation, because it is 
not so disagreeable to the taste as the corresponding salt of sodium; 
and, more important still, it is far less apt to disorder the stomach 
than salicylic acid or any of its other salts. The author has found it 
for these reasons very useful in acute articular rheumatism when the 
progress of the patient was delayed by the inability of his stomach 
to retain the ordinary antirheumatic remedies. The salicylate of 
strontium is best given in capsule or cachet, and should always be 
followed by a draught of milk or water to prevent its coming in contact 
with the stomach in too concentrated form. The dose is, for all 
practical purposes, identical with that of the salicylate of sodium. 

Strontium possesses no toxic power whatever, and overdoses are not 
followed by unpleasant consequences. If the strontium is contami- 
nated by barium, serious effects are produced. 



STROPHANTHUS. 493 

STROPHANTHUS. 

Strophanthus, U. S., Strophanthi Semina, B. P., is an African plant 
(Strophanthus kombe), from the seed of which the natives make kombe 
arrow poison. There are many varieties of strophanthus. The 
active principle is Strophanthinum (U. S.), which can be obtained 
in crystalline form and a second active principle strophanthidin. 
Although Strophanthus Kombe is the official plant it has been found 
that at least twenty varieties of strophanthus are on the market. 
Only three of these have been carefully studied and most of these 
investigations have naturally been on the strophanthin derived 
from S. Kombe. These three varieties are Strophanthus Kombe, 
Strophanthus hispidus, and Strophanthus gratus, and much of the 
tincture of strophanthus on the market probably comes from these 
and other sources. This would be of little importance were it not 
that even the strophanthin which is obtained from Kombe varies 
greatly quantitatively and qualitatively. It cannot be tested chemic- 
ally and Rowe has shown in twenty-two samples tested physiologically 
there was a variation so great that one was 67 per cent, of standard 
and another 240 per cent, of standard. Further than this some 
samples of strophanthin seem to be absorbed more readily than others. 
These facts probably account in part for the success of strophanthus 
in some cases and its failure in others. (See below.) 

The active principles of Strophanthus gratus is called Ouabain, 
which is sometimes used as a substitute for strophanthin. Its dis- 
advantage, according to Rowe, is the great variation in its power and 
it has not been as well studied. Like strophanthin it appears on the 
market in solution in ampoules containing 0.0005. This dose is the 
maximum. It should not be repeated oftener than once in twenty- 
four hours and is given intramuscularly, not subcutaneously or intra- 
venously. Ouabain is not official. 

It has been claimed that strophanthus contains a local anaesthetic 
principle, but de Schweinitz and the author found it to be possessed 
of this power only in dogs, and not in man. 

Physiological Action. — Strophanthus acts as a stimulant to the heart 
muscle, but does not slow the pulse by its action on the vagi, as does 
digitalis. While it raises arterial pressure by the increased heart 
action, it does not stimulate the vascular system to any extent. It 
is, therefore, useful in cases of weak heart with arterial spasm, since it 
helps the heart, but does not increase its work by raising arterial 
tension. 

Therapeutics. — Strophanthus may be used to supplant digitalis in 
all forms of cardiac disease, but it is not its equal, and it is to be recalled 
that so large a part of the active principles of the drug is destroyed 
in the alimentary canal that the use of the drug by the mouth is an 
uncertain method of medication. Furthermore it is very slowly 
absorbed and so its effects are uncertain, and if the doses are large it 



494 DRUGS. 

is prone to produce an active diarrhoea. The fact that the dose of the 
tincture is about the same as tincture of digitalis, although the amount 
of strophanthin it contains makes it about 150 times as toxic if it is 
tested upon the frog's heart, proves that only a little of it is really 
absorbed, and when doses as small as 5 minims (0.3) are given any 
benefit comes from other factors. 

Strophanthus is often better than digitalis in cases of weak heart 
with high arterial tension, as it exerts no effect upon the bloodvessels, 
as does digitalis. 

As is well known, there are a certain number of cases in which 
digitalis fails to do good, the explanation being that under such cir- 
cumstances the transmission of impulses over the bundle of His is 
delayed or arrested by its influence. Strophanthus often acts exceed- 
ingly well in these instances where digitalis fails. It will relieve 
cardiac dropsy by its action on the heart, but does not possess marked 
diuretic properties. Intravascular injection of strophanthin is a cer- 
tain method of getting the effects of the drug, but subcutaneous injec- 
tion is ill advised, owing to its local irritant effects. Possibly because 
the heart, under an intravenous injection, gets the whole of the dose 
used, it is a fact that the effect of the drug so given is- not only more 
marked but also much more prolonged. Intravenous injections 
should, however, be given only in very urgent cases of failing heart. 

A very useful preparation is strophanthone. It is active and 
prompt in its effects and should be employed from ampoules contain- 
ing 2| minims (0.15) diluted with normal saline to 16 minims (1.0). 
This may be given hypodermically or by the mouth in the dose of 
J to 1 mil. or intravenously in the dose of \ mil. One mil. represents 
about gV of a grain of strophanthin, so that \ mil. (about 7 drops) will 
often be sufficient. Its effects often persist, when given by the needle 
for 24 hours. 

Untoward Effects. — Strophanthus when given in full doses by the 
mouth often causes diarrhoea. It is important to bear in mind that after 
full doses of digitalis have been given a fatal result may follow the intra- 
venous use of strophanthin. Several days should elapse after digitalis 
is stopped before the strophanthin is given. 

Administration. — Strophanthus is given in the form of tincture 
(Tinctura Strophanthi, U. S., and B. P.), in the dose of 5 to 15 minims 
(0.3-1.0) (5 minims (0.3), B. P.), three times a day. The extract of 
strophanthus (Extractum Strophanthi) is now official in the B. P. 
The dose is J grain (0.015). Strophanthin (Strophanthinum, U. S.), 
may be given intravenously in the dose of j-5-g- S ram (0-0004). 

SUGAR. 

Saccharum, U. S. (Saccharum Purificatum, B. P.), is the refined 
juice of Saccharum officinarum, or sugar-cane, or that obtained from 
Sorghum, or from the sugar-beet. It is an antiputrefactive, but not an 



SULPHONAL. 495 

antifermentative. Mixed with iron preparations, it prevents oxidation. 
As it is a hydrocarbon, it is a nutrient and a developer of adipose 
tissue, or, in other words, is a food. Its use is contraindicated in 
obesity, during the existence of fermentative changes in the stomach 
and intestine, and in diabetes mellitus. 

SUGAR OF MILK. 

Saccharum Lactis, U. S. and B. P., is derived from the whey of 
cows' milk by evaporation, in the proportion of about 5 per cent., and 
is then purified by re-crystallization. It has little sweetening power 
compared to cane-sugar and possesses a peculiar insipid taste. It is, 
however, less apt to ferment and is better for infants than is cane-sugar. 

Milk-sugar is largely used in triturations, because by its hardness 
it aids in the subdivision of the medicament. It is also used to increase 
the bulk of small powders when such drugs as podophyllin and calomel 
are prescribed. It is sometimes called lactose. 

Lactose to be possessed of great diuretic power should be given in full 
doses. The advantage claimed for lactose as a diuretic is its direct 
action on the kidney and the slight effect exercised upon the rest of the 
organism. It is, therefore, in cardiac dropsy or renal inactivity that this 
substance is particularly indicated. The dose of lactose in cases of 
dropsy should be as great as from 2 to 4 drachms (8.0-16.0), given 
daily, dissolved in a quart (960 mils.) of water. It has been found that 
the lactose acts best in those cases in which there is little albuminuria. 
The diuretic effect is of interest in view of the well-known clinical fact 
that the too free addition of lactose to the milk of bottle-fed babies 
always causes profuse diuresis. 

SULPHONAL. 

Sulphonmethanum, U. S., Sulphonalum, B. P., is a synthetically 
prepared substance first manufactured in Germany by Baumann, and 
possesses the chemical name of diethyl-sulphone-dimethyl-methane. 
It is a colorless, odorless, solid substance, soluble in 365 parts of cold 
and 16 parts of boiling water, and in 60 parts of alcohol and 64 of ether. 
The drug is not affected by any of the ordinary acids, and is very stable. 

Physiological Action. — In medicinal doses the effect of sulphonal 
upon the low T er nervous system is practically nil. The dominant effect 
is on the brain. The drug is completely changed during its passage 
through the body. On the circulation the drug has but little effect ; upon 
the respiration it acts as a depressant only when given in very full doses. 

Therapeutics. — Sulphonal finds its place in medicine as a somni- 
facient or hypnotic, valuable when functional nervous insomnia is 
present, useless where advanced disease, such as cardiac trouble, is 
responsible for the wakefulness. In insanity it often produces sleep, 
and is of great service in the various mental disturbances character- 



496 DRUGS 

ized by lack of sleep and often affecting persons of unsound mind. 
Sulphonal is not as useful an hypnotic as veronal or veronal sodium. 
It possesses sleep-producing power of moderate amount — not equal 
to chloral, but ^Tcater than that of paraldehyde — and it will some- 
times succeed where the other hypnotics fail. It has the great ad- 
vantage of not being a depressant to the heart. 

Administration. — Sulphonal being virtually insoluble in cold water, 
may be given in large capsules or in mucilage of acacia, so as to be 
held in suspension until swallowed. The insolubility and bulki- 
ness of the drug render its use difficult. It is best given in hot water 
(about 6 ounces), as suggested by Stewart. This makes a solution, 
and as soon as the liquid is cool enough to be swallowed it should be 
taken before precipitation occurs as the result of cooling. Sulphonal 
should be used several hours — say two or three — before the patient 
retires. If taken late at night, the patient frequently fails to sleep 
until the morning hours, and is heavy and drowsy all the next day. 
This difficulty is partly avoided by the use of a hot solution, but even 
then it is apt to arise. The dose is 20 to 40 grains (1.3-2.6). It is wise 
not to use sulphonal continuously for more than a few days. 

Untoward Effects. — When sulphonal is taken in full dose for long 
periods of time, great sleepiness and weariness, with an unsteady 
gait, develop, which may go on to paralysis of the lower extremities 
if the use of the drug is persisted in. In some cases the paralysis is 
progressive, and in others hyperesthesia and abnormal sensations 
develop. In many such cases there is great disturbance of digestion 
with scanty secretion of urine, which contains an unusual substance, 
giving this secretion the color of port wine (hsematoporphyrinuria). 
This is partly due to a cumulative effect of the drug. 

Sulphonal often produces mental heaviness and a staggering gait 
the day after it is taken in a single dose. This can to some extent 
be avoided by giving a dose of some laxative when the drug is taken, 
so that the bowels will be moved thoroughly the next morning. There 
are a number of cases of death on record from acute and chronic 
poisoning by sulphonal. In both classes of cases the death was by 
respiratory failure preceded by profound unconsciousness. As much 
as 120 grains (8.0) have been taken, however, without ill effect, and 
Neisser has reported a case which recovered after 1400 grains had 
been taken. Probably but a small amount of this dose was actually 
absorbed. In cases of subacute or chronic poisoning the prognosis 
is unfavorable if the symptoms are well developed. 

SULPHUR. 

Sulphur is a non-metallic element official in four forms in the 
U. S. P. — namely, as Sulphur Sublimatum, U. S. and B. P., or sub- 
limed or flowers of sulphur; Sulphur ProBcipitatum, U. S. and B. P., 
or precipitated sulphur; Sulphur Lotum, U. S., or washed sulphur'. 



SULPHUR 497 

Much confusion exists among students as to the differences between 
tnese various forms of sulphur. Sulphur itself is an element which 
is prepared for medicinal uses by being heated and sublimed (Sulphur 
Sublimatum) , or flowers of sulphur. Sulphur lotum, or washed sul- 
phur, is prepared in order to get rid of sulphuric acid and other con- 
taminating substances, and is made from sublimed sulphur. Sulphur 
proBcipitatum is also made from sublimed sulphur, and is more 
bland and minutely subdivided. Some believe it differs from sublimed 
sulphur in its therapeutic properties by reason of a small amount of 
water supposed to be present. It is sometimes called milk of sulphur. 
When sulphur is prescribed for internal use the sublimed sulphur is 
generally designated. 

Physiological Action. — Sulphur has little physiological influence over 
the general system. When taken internally it causes a soft, mushy 
stool of a yellow color which often has a strong odor of hydrogen 
sulphide. The drug acts particularly on the skin and mucous mem- 
branes as a gentle alterative. The juices of the intestines break up 
some of it into sulphuretted hydrogen and sulphides. 

Therapeutics. — Sulphur is used as a mild laxative, never as a purge. 
In stricture of the bowel the soft stools produced by it will often slip 
by the obstruction, and it is worthy of note that sulphur will some- 
times overcome constipation when nothing else will give relief. It is 
particularly valuable in the treatment of constipation where there 
are hemorrhoids, and in chronic rheumatism and sciatica it is thought 
by some to effect a cure. 

Sulphur is of service in the treatment of chronic bronchial affec- 
tions, but for some curious reason its use has become almost obso- 
lete. Graves recommended 5 to 10 grains (0.30-0.60) of sulphur 
three times a day wherever bronchial secretion was excessive, and 
found that it rid the lungs of mucus and relieved the cough. 

The external use of sulphur is very much more important than its 
internal use, in so far as regards affections of the skin. Of itself, 
the drug exercises little effect over the cuticle when used in powdered 
form, but combination with an ointment makes it at once active. Even 
irritations of the skin may ensue from its constant use in large amount. 

In scabies, or itch, sulphur ointment (Unguentum Sulphuris, U. S. 
and B. P.) is the best remedy we have. The female parasite burrows 
under the epiderm and deposits the ova as she moves about, while the 
male does not burrow, but stays on the surface. The ointment will 
kill him, as he is readily attacked, but the female is protected by her 
burrowing propensities. To get at her and the ova the burrows must 
be opened, and this may be accomplished by a thorough soaking of 
the body with soap and water, thereby softening the epiderm covering 
the parasite, which can then readily be removed by rubbing the patient 
with a rough towel. The towel should be boiled at once to prevent 
its conveying the parasite to others. The ointment, if now applied, 
relieves the patient almost at once. It is important that the skin be 
32 



498 DRUGS 

well softened and rubbed, in order to keep open every burrow. The 
ointment should be allowed to remain on the part all night and be 
used for three or four nights consecutively. 

Young women often suffer from acne, particularly about the men- 
strual epoch, the skin also becoming at this time sallow and muddy. 
The following ointment is one. which is very successful in promoting 
a cure: 

1$ — Sulphuris prsecipitati oj (4.0). 

Adipis lanse hydrosi oj (30.0). — M. 

S. — Apply once or twice daily. 

Administration. — Sulphur is given in the dose of 10 to 20 grains 
(0.60-1.3) three times a day as an alterative, and from 1 to 2 drachms 
(4.0-8.0) at night as a laxative, with a little molasses to form a paste. 

A confection (Confectio Sulphuris) is official in the B. P., dose 10 
grains to 2 drachms (0.60-8.0), as is also Trochiscus Sulphuris. 

Sulphide of Calcium. 

(See Calcium, Calx, and Sulphides.) 

SULPHURIC ACID. 

Acidum Sulphuricum, U. S. and B. P., sulphuric acid, or oil of 
vitriol, is a powerful irritant and escharotic, rapidly dehydrating and 
carbonizing the tissues, causing them to become black. It is the 
most astringent of the medicinal mineral acids, and when absorbed 
it unites with bases to form sulphates, and is so eliminated by the 
kidneys, the lower bowel, and the skin. It coagulates albumin. 

Poisoning. — The symptoms produced by poisonous doses are those 
of a gastro-intestinal inflammation of the most severe type, or the 
patient may drop to the floor almost at once, owing to collapse depend- 
ent upon perforation of the walls of the oesophagus or stomach by 
the acid and its consequent escape into the peritoneal cavity. If the 
patient lives to the fourth day, the parotid glands may become swollen 
as the result of stenosis of the salivary ducts of Steno, and violent 
inflammation of the kidneys may appear from the passage of the 
drug through these organs in the process of elimination. If partial 
recovery takes place, the patient often dies from inanition due to the 
formation of strictures in the alimentary canal or to destruction of 
the peptic tubules. The stain about the mouth is black, and if any 
of the acid is spilt on the clothing, the characteristic burn is to be 
seen. 

The treatment consists in the use of alkalies, such as chalk, mag- 
nesia, whitewash off walls, and soap. Opium and oils are to be given 
to allay irritation, and external heat is to be applied. 

Therapeutics. — Sulphuric acid is sometimes employed as a caustic 
to venereal sores, warts, and slowly healing ulcers, but is most com- 



SUPRARENAL GLAND AND ADRENALIN 499 

monly used internally, as it fulfils several pressing indications. As 
a remedy for serous diarrhoea, particularly if combined with some 
vegetable astringent, it is unsurpassed, and its use in cholera deserves 
great attention. (See Diarrhoea.) In the Philadelphia Hospital dur- 
ing an epidemic of cholera some years since every patient who received 
sulphuric acid improved or failed to be attacked, whereas those who 
did not receive it were either very ill or died. 

The proper way to use the drug as a prophylactic during cholera 
epidemics is in the form of "sulphuric-acid lemonade," made so that 
each wineglassful of water contains 5 drops (0.30) of the aromatic 
sulphuric acid. The same solution may be used in acute lead poisoning 
in order to form an insoluble sulphate of lead, and may be taken by 
artisans exposed to chronic lead poisoning as a prophylactic for the 
same purpose. 

Sulphuric acid combined with belladonna or morphine is often 
used in the night-sweats of phthisis. 

Administration. — The dose of the dilute acid (Acidum Sulphuricum 
Dilutum, U. S. and B. P.) is 5 to 20 minims (0.30-1.3), and of the 
aromatic acid (Acidum Sulphuricum Aromaticum, U. S. and B. P.) 
5 to 20 minims (0.30-1.3). The latter is the best preparation for 
general use. It contains tincture of ginger and oil of cinnamon. 
Both preparations should be thoroughly diluted before they are 
administered. 

SUMBUL. 

Sumbul, U. S., is a root of undetermined origin. The dose of the 
root (Sumbul Radix, B. P.) is 10 to 40 grains (0.60-2.6). On the 
nervous system sumbul acts as an efficient nerve tonic, and was largely 
employed by Goodell in cases of nervous exhaustion and in the unrest 
of nervous females. It is official in the fluidextract (Fluidextr actum 
Sumbul, U. S.), dose 5 to 20 minims (0.30-1.30), and the extract 
(Extractum Sumbul, U. S.), dose 1 to 5 grains (0.06-0.30). The 
tincture (Tinctura Sumbul, dose 1 to 4 drachms (4.0-16.0) is official 
in the B. P. Goodell used the following formula: 

1$ — Extracti sumbul gr. xx (1.3). 

Ferri sulphatis . . . . . . . gr. xx (1.3). 

Asafoetidse . . gr. x (0.60). 

Arseni trioxidi gr. £ (0.03). — M. 

Fiant pilulse No. xx. 

S. — One t. i. d. after meals. 

SUPRARENAL GLAND AND ADRENALIN. 

The suprarenal gland, or its active principle, adrenalin (Adrenalinum 
B. P.), has become within the last few years one of our most valued 
remedies. Its chief use in medicine depends upon its extraordinary 
power of producing contraction of small bloodvessels and capillaries 



500 DRUGS 

with which it is brought in contact. It also exercises a marked con- 
stricting effect on the bloodvessels of the general arterial system when 
given intravenously. 

The medullary portion of the glands is chiefly concerned with the 
elaboration of the active physiological principle, which has been 
isolated by a Japanese chemist, Takamine, and called adrenalin. 
Adrenalin occurs in tiny, almost microscopic, white crystals of various 
forms. As adrenalin is not readily soluble in water, adrenalin chloride 
is always employed and appears on the market in solution in the 
strength of 1 to 1000. As this strength is too great for local applica- 
tion in most instances it is further diluted before use by water or 
salt solution, even to 1 in 20,000. These dilute solutions are readily 
oxidized if exposed for a length of time to the air, becoming pink, then 
red, and finally brown in color and losing their efficiency. When in 
ampoules adrenalin chloride solutions can be sterilized by boiling with- 
out any loss of activity. In unsealed solutions exposed to the air 
such solutions can be sterilized by boiling once or twice without loss 
of power. 

Physiological Action. — When locally applied to mucous membranes 
extract of this gland, or adrenalin, produces great blanching by reason 
of its powerful constriction of the capillaries of the part. So great 
is this constriction that the superficial tissues are practically blood- 
less while its influence lasts. This local effect is due to stimulation 
of the muscular fibres in the bloodvessel walls. Its use is not followed 
by the great relaxation and congestion seen as a secondary effect after 
the local application of cocaine to a mucous membrane. Given 
intravenously, it slows the pulse by stimulation of the vagus nerves 
and by the increased arterial pressure which is due to the contraction 
of the muscular coats of the bloodvessels, which causes an increase in 
the resistance to the free flow of blood, but this effect is very fleeting. 
This fleeting effect is not due to a rapid destruction or elimination of 
adrenalin, but rather depends upon its inability to maintain its primary 
influence. This is proved by the fact that if the bloodvessel going to 
a limb is ligated, thereby cutting off its blood supply, and adrenalin is 
injected into the vessels of the rest of the body, it causes a contraction 
of all the bloodvessels except those in the ligated part. If after its 
effects upon the general vascular system have disappeared, the ligature 
is removed, so permitting the blood to enter the limb, the bloodvessels 
in the hitherto protected part undergo powerful constriction, which 
proves that there is still active adrenalin in the circulating fluid. The 
constriction of the bloodvessels is due to the action of the drug on the 
vessel walls and not to a centric vasomotor influence. 

Upon the venous system, when not locally applied, its effects may 
be ignored. It also increases the force of the systole of the heart 
by stimulating its muscular fibres. In other words, the effect of 
adrenalin upon the circulatory system is very similar to that of digi- 
talis, but is more feeble and fleeting. It is important to recall the 






SUPRARENAL GLAND AND ADRENALIN 501 

fact that the pulmonary vessels are not affected by adrenalin, and 
that even the direct application of this substance to the lung does 
not cause local ischsemia. Although it constricts the fibres of the 
systemic bloodvessels it relaxes the bronchial muscularis. Further, the 
constricting effect on the vessels of the cerebrum is very slight. The 
vessels of the uterus are strongly affected, but those of the bladder 
are but slightly influenced. 

When injected in full dose beneath the skin or into a vein adrenalin 
causes a temporary glycosuria in many cases. 

Therapeutics.— Because of its extraordinary power in constricting 
bloodvessels of small calibre adrenalin is a remedy in all forms of 
hemorrhage from such vessels, if it it can be locally applied. 

Thus, it can be employed in epistaxis,menorrhagia, metrorrhagia, and 
for the purpose of controlling hemorrhage in operations on the nose, 
throat, ear, or larynx It can also be employed to relieve the engorge- 
ment of the nasal mucous membrane in cases of asthma, coryza, and hay 
fever, and in trachoma and conjunctivitis. 

An acute attack of bronchial asthma can sometimes be rapidly and 

Fig. 64. 



/irx 



f 



Showing the rise of arterial pressure produced by the injection of 0.00004 of adrenalin 
into the vein of a dog. 

completely relieved by the hypodermic injection of 5 to 10 minims 
(0.30-0.60) of adrenalin solution, 1 : 1000 strength {Liquor Adrenalini 
hydrochloridi, B. P. This is due to the fact that adrenalin relaxes 
the muscular fibres of the bronchi. So too, an intramuscular injection 
of 10 to 15 minims (0.65-1.0) may be given in pulmonary oedema with 
advantage. (See Pituitrin.) In sudden cardiac failure and collapse 
complicating surgical procedures, a pint of normal saline solution 
should be slowly injected into a large vein, and in this solution, as it 
flows into the vessel through a rubber tube, should be placed 1 drachm 
(4.0) of adrenalin solution (1 : 1000). Cases apparently moribund have 
been resuscitated by this means. Recent investigations have seemed 
to show that adrenalin very distinctly increases the tendency to the 
ventricular fibrillation which is induced by chloroform and it would 
seem to be proved that after adrenalin has been used locally or hypo- 
dermically, chloroform as an anaesthetic is distinctly contraindicated. 



502 DRUGS 

If chloroform is used in such an instance it should be preceded by 
atropine to nullify the stimulant effect of adrenalin on the vagus 
nerves. 

It has also proved itself a valuable agent in controlling surgical 
shock. Under these circumstances the vasomotor centre is depressed 
or paralyzed and death ensues because of the vascular relaxation. 
The use of strychnine for the purpose of stimulating the vessels through 
the vasomotor centre is often useless because it is too depressed to 
respond. The intravenous injection of adrenalin acts directly upon 
the muscular fibres in the vessel walls and raises blood-pressure so 
that life is saved. When adrenalin is used in this way the ordinary 
1 : 1000 solution in which it appears on the market should be added 
to the extent of 1 to 2 drachms (4.0-8.0) to a pint of normal saline 
solution and slowly given intravenously or by hypodermoclysis. Strong 
solutions should not be used hypodermically because they cause 
ischsemia of the part injected, and this, in turn, permits germs to 
grow, and so a slough may ensue. 

Adrenalin is largely and wisely used in association with local anaes- 
thetics, such as cocaine, etc., to increase their local effect by confining 
them to the part to which they are applied, and it greatly diminishes 
the danger of their absorption into the system by diminishing the blood 
supply of the part to which it is applied. 

Certain clinicians also assert that the injections of 5 to 15 minims 
(3.0-1.0) of adrenalin solution, 1:1000, into inoperable sarcomatous 
and carcinomatous growths results in a marked arrest in the develop- 
ment of the tumor and in a gain in weight on the part of the patient. 
If the injection causes pain it may be preceded or accompanied by 
novocaine. In pernicious vomiting of pregnancy, without albumin- 
uria, 20 minims (1.3) of the 1:1000 solution in salt solution may be 
given hypodermically with advantage in some cases. 

Administration. — Suprarenal gland may be given in desiccated form 
Suprarenalum Siccum, U. S.) in the dose of 3 to 10 grains (0.20-0.60), or 
as an extract of the gland, in the dose of 3 to 5 grains (0.20-0.30) three 
times a day or oftener. By far the best form in which to use it is 
adrenalin chloride in normal salt solution, 1 : 10,000 to 1 : 1000 (Liquor 
Adrenalinum Hydrochloricus , 1 to 1000, B. P.). Adrenalin may be given 
internally in solution to check hemorrhage from the stomach, but if 
it is being used in a case of shock its action by this method is too 
slow and the gastric juice certainly diminishes its activity or destroys 
it before it can be absorbed. When used locally it is employed by 
wetting a pledget of cotton with the solution named and then pressing 
it lightly against the part which it is desired to affect. Blanching comes 
on in a few moments. A solution of 1 : 10,000 or stronger may also 
be brought in contact with the part by means of an atomizer. 



SWEET SPIRIT OF NITRE 503 



SWEET SPIRIT OF NITRE. 

Sweet spirit of nitre (Spiritus JEiheris Nitrosi, U. S. and B. P.), or 
spirit of nitrous ether, is a mixture of alcohol, water, and ethyl nitrite. 
Spirit of nitrous ether should contain not less than 3.5 per cent, of ethyl 
nitrite. It is upon this last constituent that most of its value as a 
remedial agent depends. The drug when sold by pharmacists or others 
who are not careful to keep fresh preparations is no better than alcohol 
and water alone, since the ethyl nitrite readily escapes, and deteriora- 
tion at once takes place. When freshly prepared and medicinally 
active this preparation should, as its name indicates, be sweet in taste. 
If it is acid, turns blue litmus red, or effervesces on the addition of 
bicarbonate of potassium or sodium it should be rejected. When 
sweet spirit of nitre is impure because of the presence of free acid, and 
is mixed with antipyrin, a purple color followed by a green precipitate 
will be formed. This green precipitate is iso-nitroso-antipyrine, 
which is not in the least poisonous, but such a sample of nitre should 
be discarded. 

Physiological Action. — Sweet spirit of nitre is a sedative to the cir- 
culatory and nervous systems, as are all the nitrites (see Nitrite of 
Amyl) and a diaphoretic and diuretic, according to the manner in 
which it is administered. If given in very full doses, it rapidly 
produces the cyanosis characteristic of the full effects of any one of 
the nitrites. (See Amyl Nitrite.) 

Therapeutics. — There is probably no drug so widely employed by 
the laity as a household remedy which is so potent for good, and yet 
so harmless, if wrongly used, as is this one. 

Physicians often place less reliance upon it than it deserves, and 
in nearly every instance where it fails it is either not indicated or the 
nitrous ether has escaped and left it powerless. 

In incontinence of urine in children the combination which follows 
is very useful in certain cases. (See also Incontinence of Urme, Part 
IV.) In these instances the urine will be found high-colored, acici, and 
concentrated, and therefore capable of irritating the bladder and 
genito-urinary tract: 

1$ — Potassii citratis oj to oij (4.0-8.0). 

Spiritus setheris nitrosi f 5ss (16.0). 

Aquae destillatse . . . . q. s. ad f §iv (120.0). — M. 
S. — Dessertspoonful (8.0) every five hours until the urine becomes clear. 

As soon as the urine is clear and neutral, belladonna may be used, 
the citrate of potassium and sweet spirit of nitre being continued or not 
as the case demands. When the spinal centres are depressed and there 
is general atony of the system, it may be well to substitute the fol- 
lowing pill for the belladonna: 

1$ — Arseni trioxidi gr. \ (0.015). 

Extracti nucis vomicae gr. ij (0.12). 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulee No. xx. 

S. — One pill t. i. d. after meals. 



504 DRUGS 

The diuretic action of sweet spirit of nitre is best obtained by using 
the drug in ice-cold water and keeping the patient lightly covered 
and cool. On the other hand, if a diaphoretic influence is desired, 
it may be given simultaneously with warm lemonade, and the patient 
should be well blanketed. This last action of sweet spirit of nitre 
has made it a remedy of common use in treating acute colds in adults 
and children, and in diminishing the fever of these conditions in the 
latter class as well. 

Sweet spirit of nitre is a distinct antispasmodic, and can be well 
employed where slight nervous excitement accompanies fevers or in 
other states associated with nervous irritation in infancy. 

The dose for an adult is from 20 minims to 2 drachms (1.3-8.0), 
and for a child of one year 5 to 10 minims (0.30-0.60). It should 
always be given in cool water to the latter class of patients. 

TAMARINDS. 

Tamarindus, B. P., is the preserved pulp of Tamarindus indica, a 
tree of the West Indies. 

The taste is a peculiar mixture of bitter and sweet. As a laxative 
it exerts little power over that of any ordinary fruits, such as apples, 
but it enters into the confection of senna (Confectio Sennce, U. S. and 
B. P.), Patients often find tamarinds a very agreeable laxative when 
they are taken before going to bed or eaten as a confection after meals. 

TANNIC ACID. 

Tannic acid (Acidum Tannicum, U. S. and B. P.) when pure is 
an uncrystallizable, white or yellowish-white powder, without bitter 
taste and very soluble in water and glycerin. It is not soluble in 
alcohol or ether. It is the chief active principle of vegetable astringents, 
and occupies the relative position of an alkaloid to a crude drug, so 
far as the active portion of these vegetable astringents is concerned. 
Tannic acid is derived from nut-gall. 

Physiological Action. — Tannic acid when brought in contact with 
any of the tissues of the body constringes them and decreases their 
vascularity for a time, by causing contraction of their bloodvessels. 
For these reasons it stops secretion and constringes parts of the body 
which are relaxed and feeble. Mixed with blood, it forms a clot with 
great rapidity through coagulation of the albumin. Tannic acid is 
absorbed as gallic acid and eliminated as such, only acting as tannic 
acid before absorption. This is important to remember, since we 
learn from this that tannic acid is to be used to check hemorrhage 
only where the drug can be brought in direct contact with the bleed- 
ing point. 

Therapeutics. — Tannic acid is used in medicine to control hemor- 



TAR . 505 

rhage, and to act as an astringent to relaxed tissues, as in diarrhoea 
of the atonic or serous type, or in localized or general sweating. It 
is also of service for the purposes of toughening mucous membranes 
or parts of the skin which are exposed to much rubbing, as in the 
case of the nipples of a primipara, or where the feet become macer- 
ated and sore or sweat profusely on exercise being taken. (See 
Formaldehyde.) In the treatment of haemoptysis tannic acid may be 
dissolved in water in the proportion of 5 to 10 grains (0.30-0.60) to 
the ounce (30.0) and used in a fine spray delivered from an atomizer. 
Glycerite of tannin is made by adding 2 ounces (60.0) of tannic acid 
to a J pint (240 mils.) of glycerin, and mixing at a gentle heat until 
solution occurs. It is useful as an application to indolent ulcers and 
depressed mucous membranes, as after an attack of stomatitis. In 
hemorrhoids of the bleeding type tannic-acid suppositories are often 
very useful, and cotton saturated with tannic-acid solution is often 
used as a packing in vaginal leucorrhoea. 

Administration. — The dose of tannic acid is 2 to 10 grains (0.12- 
0.60), best given in pill. The official preparations are — the troches 
(Trochisci Acidi Tannici, U. S.), each containing 1 grain of tannin; 
the Glyceritum Acidi Tannici, U. S.; Collodium Stypticum, U. S.; 
and an ointment (Unguentum Acidi Tannici, U. S.). The B. P. pre- 
parations are — Glycerinum Acidi Tannici; Suppositoria Acidi Tannici, 
each containing 3 grains (0.20) ; and Trochiscus Acidi Tannici, of which 
each contains J grain (0.30) of the acid. 



TANSY. 

Tansy (Tanacetum) is the leaves and tops of Tanacetum vulgar e, 
yielding a volatile oil (Oleum Tanaceti) which possesses emmenagogue 
powers and has been largely used as a uterine stimulant. It is also 
used as an anthelmintic. 

In poisonous dose it causes epileptiform convulsions in some cases, 
and deep coma, with death from respiratory failure. 

The dose of the oil as an emmenagogue is 1 to 3 drops (0.06-0.20). 

In domestic medicine tansy tea, made by adding 1 ounce (30.0) of 
the leaves or tops to 1 pint (480) of hot water, and given in the dose 
of 1 to 2 ounces (30.0-60.0), is largely employed as a remedy for 
amenorrhea. 

TAR. 

(See Pitch, p. 446.) 

Under the name of Pix Liquida, U. S. and B. P., or tar, we have an 
empyreumatic oleoresin obtained by destructive distillation from Pinus 
palustris (Sylvestris, B. P.) and other varieties of pine. It is a thick, 
dark oil, slightly soluble in water and soluble in alcohol, oils, and solu- 



506 DRUGS 

tions of potassa and soda. By distillation of tar we obtain oil of tar 
(Oleum Picis Liquidce Rectificatum , U. S.), which is used in bronchitis by 
inhalation from an atomizer, but is not a particularly useful applica- 
tion. It should be diluted with some other oil or with fluid cosmoline. 
Tar itself is used in subacute and chronic bronchitis in 2-grain (0.12) pills, 
and as a remedy for g astro-intestinal catarrh. Externally, it is used in 
psoriasis and other skin diseases needing stimulation. For the relief 
of obstinate diarrhoea Wood has highly recommended a mixture of tar 
made as follows : Add a pint of tar to a gallon of lime-water, and allow 
this solution to stand one week, stirring it every few hours. Decant 
the clear liquid and percolate it through powdered wild-cherry bark, 
allowing 1 ounce of the bark to be present for each pint passed through 
it. The dose is a wineglassful (60.0). 

In chronic bronchitis tar-water is largely used, as a popular remedy, 
in Europe and England. Tar-water is made by shaking 1 part of 
tar with 4 parts of water several times during twenty-four hours, 
decanting, and filtering. The dose is from 1 to 2 pints (J-l litre) 
a day as a drink. It at first increases the expectoration, but finally 
decreases it. 

Syrup of tar (Synipus Picis Liquidce, U. S.) is simply sweetened 
tar-water. 

In skin diseases of the dry, scaly sort, such as psoriasis, tar oint- 
ment (Unguentum Picis Liquids, U. S. and B. P.) is very useful if 
frequently applied, or the following may be used: 

1^ — Sulphuris praecipitati 

Picis liquidae aa 3vj (24.0). 

Saponis viridis, 

Adipis aa §ij (60.0). 

Pulveris cretse oiv (16.0). 

If the skin is tender, this prescription should be diluted with lard. 
Sometimes children will suffer from a persistent dry chronic eczema 
which resists all treatment; the following may then be employed with 
advantage. 

1^ — Picis liquidse 5ss (2.0). 

Sulphuris praecipitati qss (2.0). 

Unguenti zinci oxidi oj (30.0). 

S. — Apply night and morning. 

Tar should not be used on the face, as it will stain the skin. 

Wine of tar (Vinum Picis) is made by adding together tar 1 pint, 
glycerin, white wine, and honey of each J a pint, dilute acetic acid 
1 ounce, and 3 parts of boiling water, and shaking constantly at a 
temperature of 160° F. for several hours. This mixture is then set 
aside for some days and repeatedly filtered or strained through muslin. 
The dose is 1 to 4 ounces (30.0-120.0). It may be used instead 
of tar-water or tar-syrup. 



TEREBENE 507 

TARAXACUM. 

Taraxacum, U. S., Taraxici Radix, B. P., dandelion, is a very old 
remedy for hepatic torpor and the dyspepsia resulting therefrom. It 
should be prepared from the fresh leaves or roots, as the dried plant 
is inert. From disregard of this fact much disappointment has arisen. 
Owing to its being bitter it acts as a tonic. The extract (Extractum 
Taraxaci, U. S. and B. P.), dose 5 to 30 grains (0.30-2.0), and the 
fluidextract (Fluidextractum Taraxaci, U. S., dose 1 to 3 drachms 
(4.0-12.0), are the only official preparations. Succus Taraxaci, B. P., 
is given in the dose of 1 to 2 drachms (4.0-8.0). 



TARTARIC ACID. 

Acidum Tartaricum, U. S. and B. P., is derived from crude potas- 
sium bitartrate, and is much less powerful than acetic acid, but capable 
of producing very severe gastro-enteritis if taken in overdose and in 
concentrated form. It is rarely used alone, and is most commonly 
employed to act upon sodium or potassium bicarbonate to form effer- 
vescent drinks. (See Seidlitz Powder and Effervescing Draughts.) 
The dose is 5 to 10 grains (0.30-1.3). 

When tartaric acid is taken in poisonous dose, lime-water, alkalies, 
and magnesia are the antidotes, and opium is to be given to allay 
irritation. If necessary, emetics are to be used. 

TEREBENE. 

Terebenum, U. S. and B. P., is a clear, thin, colorless liquid, slightly 
insoluble in water, having a peculiar odor like that of new pine sawdust, 
and is made by the action of sulphuric acid upon oil of turpentine, 
which is then distilled at about 160° F. 

Therapeutics. — Terebene is a useful stimulating expectorant, in 
the late stages of acute or in chronic bronchitis to liquefy and get rid 
of the mucus which is clogging the bronchial tubes. The drug may 
be given by way of the stomach or by inhalation. A useful mixture 
in the later stages of bronchitis when the mucus is very thick and 
tenacious is one composed of equal parts of terebene, iodide of 
ethyl, and chloroform, placed on a sponge and held some two or 
three inches from the face. It has also been employed in genito- 
urinary inflammations of a subacute or chronic form in place of oil of 
sandal-wood or copaiba as a stimulant. In fermentative dyspepsia it 
is of service as an antiseptic. The drug should always be given in 
capsule in the dose of 5 to 10 minims (0.30-0.60), or by dropping it on 
sugar in the same amount. This dose may be repeated every three 
hours. Unfortunately, terebene is very apt to irritate the stomach or 
to produce diarrhoea, and it sometimes irritates the kidneys. 



508 DRUGS. 



TERPINE HYDRATE. 

Terpine hydrate (Terpini Hydras, U. S.) is prepared by a process, 
unnecessary to explain here, from a mixture of pure oil of turpentine, 
alcohol, and nitric acid. In this manner large colorless crystals, 
nearly odorless and with a faint taste, are formed, and in this form 
the drug appears on the market. Terpine hydrate is soluble in 200 
parts of cold, 34 parts of boiling water, and in 13 parts of alcohol. Of 
ether it requires 140 parts for its solution, and of chloroform 135 
parts. 

Therapeutics. — Terpine hydrate is used for the purpose of increas- 
ing secretion from pharyngeal, laryngeal, and bronchial mucous 
membranes, and is a useful remedy in subacute or chronic bronchitis 
to rid the tubes of mucus. The drug has also been satisfactorily 
employed in the treatment of hay fever when given in full doses. 
The remedy, while useful in only a limited number of conditions, 
certainly seems to be very useful in the diseases named. The dose as 
generally given is 2 to 3 grains (0.12-0.20), but it may be given in the 
dose of 15 to 20 grains (1.0-1.3) three times a day in hay fever. Ter- 
pine hydrate may be prescribed in pill, capsule, and in alcoholic solu- 
tion flavored with some of the aromatic waters and with the addition 
of a little syrup. Thus : 

1^ — Terpini hydratis gr. lxxv (5.0). 

Spiritus vini gallici f §ij (60.0). 

Syrupi lactucarii, 

Syrupi tolutani aa f §iij (90.0). — M. 

S. — 1 to 2 dessertspoonfuls (3.0-16.0) three or four times a day. 

Or we may prescribe — 

1^— Terpini hydratis gr. xl (2.60). 

Acidi benzoici gr. xl (2.60). 

Codeinae gr. v (0.3).— M. 

Fiant pilulae No. xx. 

S. — One pill three or four times a day. 

An elixir of terpine hydrate with heroin is now widely sold, and is a 
useful preparation to act as an expectorant and allay excessive cough. 
This preparation is contained ,in the National Formulary under the 
name of Elixir Terpini Hydratis cum Heroina. Each drachm (4 mils.) 
of it contains 1 grain (0.06) of terpine hydrate and ^t grain (0.004) of 
heroin; the dose is 1 to 2 drachms (4.0-8.0 mils.) every three hours. 

The nitric acid test for albumin in the urine is fallacious if the terpine 
hydrate is being taken. 

TERPINOL. 

Terpinol is derived from terpine hydrate by boiling the latter with 
dilute mineral acids. Terpinol is an oily substance with an odor 
resembling that of hyacinths. It is almost insoluble in water, but 



THIOCOL 509 

dissolves readily in ether and alcohol. It is used for the same purpose 
as terpine hydrate, in the dose of 8 to 20 grains (0.5-1.3), in capsule or 
pill. This dose may be given twice or thrice a day. The drug may 
irritate the stomach and kidneys when given in overdose. 



THAPSIA. 

Thapsia garganica is an umbelliferous plant of Southeastern 
Europe, employed for the purpose of producing a blister. It is gen- 
erally used under these circumstances in the form of a plaster. The 
resin, obtained from the bark of the root, is the form in which it appears 
in medicine. When applied continuously it produces great irritation, 
and finally sloughs result. 

THEOCIN. 

Theophyllina, U. S., is a minor alkaloid found in tea leaves. It is 
insoluble in water, somewhat irritant to the stomach, and is a dimethyl - 
xanthin in distinction from caffeine or theine, which is trimethylxan- 
thin. 

Because of its insolubility, acet-theocin-sodium has been made from 
a synthetic theocin, as it is soluble in 25 parts of water and contains 
65 per cent, of theocin. Acids and acid fruits are not to be given 
with acet-theocin-sodium as they will precipitate theocin. 

Physiological Action. — The chief influence of this drug is exercised 
upon the secreting epithelium of the kidney, upon which it acts as a 
stimulant and if the kidney be inflamed as an irritant. It is there- 
fore to be used with caution in acute nephritis if at all. 

Therapeutics. — The best effects of Acet-theocin-sodium are produced 
in the relief of cardiac dropsy, in which state it is said to often cause 
profuse diuresis. It does much less good in renal dropsy. As its 
effect on the heart is slightly stimulant it aids diuresis by increasing 
circulatory activity. Unfortunately, the drug loses its effects after it is 
used for four or five days. It should be stopped for several days and 
then given again. The dose is 2 to 3 grains (0.1-0.15), dissolved at 
each administration in pure water and given twice or thrice a day after 
food. 

THIOCOL. 

Thiocol is derived from guaiacol, the chief active ingredient of 
creosote, and is, technically speaking, potassium guaiacol-sulphonate. 
It is a white fine, crystalline powder, readily soluble in water and 
in diluted alcohol, and possessing a slightly bitter, salty taste. Thiocol 
is used in medicine as a substitute for creosote and guaiacol in the 
treatment of chronic bronchitis and tuberculosis of the lungs, and is 
given in the dose of 10 to 30 grains (0.60-2.0) three times a day. Its 



510 DRUGS 

advantages are its comparative tastelessness, its ready absorbability, 
and the fact that it does not irritate the stomach. It may be given 
in powder on the tongue or in capsule. 

THIOSINAMINE. 

Thiosinamine is derived from volatile oil of horseradish, or more 
commonly from the volatile oil of mustard-seed, by the addition of 
alcohol and ammonia-water and exposing it to heat. Under these 
conditions crystals of thiosinamine are deposited in prisms which are 
soluble in 2 parts of warm water, and in alcohol or ether. A solution 
of it should not redden litmus paper. 

When given by the mouth the dose is \ to 1 grain (0.03-0.06) three 
times a day. Larger doses may disorder the stomach. If this does not 
occur, as much as 3 grains (0.2) may be used. Thiosinamine is used also 
for the cure of lupus in scars, and keloid, and it has been used with 
asserted success in malignant growths. In a case of keloid the drug is 
10 per cent, solution in absolute alcohol may be injected directly into 
the part affected in the dose of 10 to 20 minims (0.60-1.3) every third 
or fourth day. The part receiving the injection usually becomes con- 
gested and swollen and dark in hue. There is often a great increase 
in the quantity of the urine, and perhaps nausea and vomiting, and 
great pain where the injection is given. In cases of lupus it may be 
injected locally or at a distant spot, and produces a reaction like that 
caused by tuberculin. Before thiosinamine is used it is necessary to 
exclude the possibility of the presence of any other old inflammatory 
focus, particularly if it be tubercular in origin, since the drug may light 
up a partly healed lesion into an active inflammatory process. 

The effect of thiosinamine upon certain abnormal tissues is extra- 
ordinary. When injected subcutaneously, or when given by the 
mouth in some instances, it causes a local reaction in those parts of 
the body in which scar tissue exists or where poorly developed patho- 
logical tissues are present. Because of this reaction the part affected 
undergoes more or less resolution and absorption takes place. After 
a hypodermic injection the effect is produced in a few hours, but 
when given by the mouth the effect is produced more slowly, if at all. 
The duration of the effect of a single dose is about five hours. Because 
of the softening which it causes in sclerotic tissues it has been used 
for the removal of scars, for the dissipation of corneal opacities, and 
for the relief of deafness due to thickening of the drum or fixation of 
the aural bones. For some reason thiosinamine has not become as 
popular as its action upon some tissues would lead us to expect. ^ A 
modified form of thiosinamine, called Fibrolysin, made by mixing 
thiosinamine with sodium salicylate, possesses the advantages of being 
soluble in water, but this solution has to be freshly made, as it 
soon undergoes oxidation, or it can be put up in sealed vials each of 
which contains one dose of 20 grains (1.3) of fibrolysin, which is equiva- 



THYMOL. 511 

lent to about 3 grains (0.2) of thiosinamine. The best way to use it is 
by intramuscular injection, which is said to be painless. Although 
highly praised by many German clinicians, fibrolysin, like thiosina- 
mine, has never become popular in this country. One of the chief 
objections to its use is that it may cause the breaking down of inflam- 
matory exudates designed by nature to protect the body, as well as 
harmful exudates. Thus its use may cause the spread of a partly 
healed tuberculous focus. 

THYMOL. 

Thymol, U. S. and B. P., is derived from the oil of thyme and other 
volatile oils, and occurs in large crystals. It is soluble in water 1 
to 1500, but is freely soluble in fats and oils. Thymol is irritant in 
large amount. It is antiseptic and germicidal, and in saturated solu- 
tion in water is the most efficient antiseptic mouth-wash. Thymol 
is an excellent remedy in uncinariasis. Under these conditions it 
should be used in gelatin-coated pill or konseal, and a glass of water 
or milk taken to avoid the burning sensation otherwise produced. 

When thymol is to be given for hookworm, all fatty foods are forbidden, 
as this drug is soluble in fats, and when dissolved is readily absorbed, 
which is undesirable. The patient is starved for twelve hours, then 
purged with magnesium sulphate, and after this the thymol is to be 
swallowed. Five hours after the thymol is given, a second dose of 
magnesium sulphate is used to sweep out the parasites. The dose of 
thymol must be fairly large, from 5 grains (0.32) for a child to 60 grains 
(4.0) for an adult. If the patient is too feeble to be actively purged, a 
dose of 5 grains every week for several weeks may be resorted to. 
The following table of doses according to age may be followed in fairly 
strong persons : 

Under 5 years . . . . up to 5 grains. 

Under 5 to 10 years . • 8 to 15 grains. 

Under 10 to 15 years 15 to 30 grains. 

Under 15 to .20 years 30 to 45 grains. 

Under 20 to 60 years 45 to 60 grains. 

After 60 years 45 grains. 

In the treatment of stomatitis or tenderness of the gums after mercurial- 
ization, the following mouth-wash may be used : 

I$— Thymolis gr. v (0.32). 

Sodii boratis gr. xv (1.0). 

Aquae f oij (60.0).— M. 

S. — Place a teaspoonful (4.0) of this in | a tumblerful of water and use as a 
gargle. 

Thymol has been used for dressing wounds, but is too costly for 
general use. In summer weather it cannot be employed, because of 
its attraction for flies, which make the patient's life miserable. 

The average dose is 2 grains (0.12), in capsule or in wafer, and it is 
better to follow its use by a glass of milk to prevent the drug irri- 



512 DRUGS. 

tating the stomach. In typhoid fever as much as 30 grains (2.0) in 
twenty-four hours have been given as an intestinal antiseptic; in this 
disease it is of little value. 

If very large amounts (100 grains [7.0]) are taken in a day, poisoning 
may result, but this much must be used before danger is present. 

Thymol Iodide. 

Thymolis lodidum, U. S., is a compound of iodine and thymol, some- 
times called aristol, but more correctly dithymol diiodide. It is 
obtained by the condensation of two molecules of thymol and the intro- 
duction of two atoms of iodine into the phenolic groups of the thymol; it 
contains 45 per cent, of iodine, and was introduced into medicine for the 
purpose of acting as a substitute for iodoform. It should be kept in 
amber-colored glass vials to protect it from light. Its color varies from 
that of chocolate to reddish yellow. It is insoluble in water and glycerin ; 
slightly soluble in alcohol at 25° C. (77° F.); readily soluble in ether, 
chloroform, collodion, and in fixed and volatile oils, leaving a slight 
residue. It is free from the unpleasant odor of iodoform, and it is 
stated to be less apt to produce poisoning by absorption. Much con- 
tradictory experience has accumulated as to its exact value, but the 
result of a careful examination of clinical reports is that in some 
respects it is a better drug than iodoform and in others not so 
good. 

Tichhoff and Neisser state that when taken internally thymol iodide is 
incapable of causing toxaemia, but this can only be true when moder- 
ately large doses are given. Upon cocci and bacilli thymol iodide 
has less power than iodoform. In regard to the power of this drug 
in healing wounds or sores, the decision has been reached that when- 
ever secretion is free it is contraindicated, as the thymol seems to 
increase moisture. On the other hand, in those instances where in 
disease of the skin or mucous membrane an undue dryness is present 
the effect produced is often favorable. Upon lupus little effect is 
produced unless the surface is first curetted. Finely powdered thymol 
iodide has been found of marked value in the treatment of inter- 
stitial keratitis by de Schweinitz and Wallace when dusted into the 
eye each day. In an ointment of \ to 1 drachm to the ounce of lard 
(2.0-4.0 : 30.0) thymol iodide may be used in psoriasis, but it is not 
so useful as is chrysarobin in this affection. 



THYMUS GLAND. 

The thymus gland has been used quite largely in certain diseases 
on the same principle as that governing the use of the thyroid, namely, 
that this gland possesses the function of internal secretion and will 
therefore benefit certain systemic conditions in persons in whom the 
thymus was atrophied too early in life. Others have used it as a sub- 



THYROID GLAND 513 

stitute for the thyroid, intentionally or by mistake. Its chief use has 
been in the treatment of goitre (not exophthalmic) . It does not produce 
any disagreeable effects as does the thyroid. Usually the beginning 
dose is \ ounce (16.0) administered several times a week. This dose is 
soon increased to an ounce (30.0) once a week. Parke, Davis & Co. 
prepare thymus gland in tablets and capsules ready for use, and this 
is the best form in which to prescribe it. 

THYROID GLAND. 

Dried thyroid gland (Thyroideum Siccum, U. S. and B. P.) is the 
cleaned, dried, and powdered glands of the sheep, freed from fat. It 
appears as a yellowish amorphous powder, having a slight, peculiar 
odor, and containing the active ingredient of the thyroid gland ; partially 
soluble in water. One part of the dried gland represents approxi- 
mately 5 parts of the fresh gland. Occasionally it represents as much 
as 10 parts of the fresh gland. 

The thyroid gland has been introduced into therapeutics within 
the last few years for the purpose of relieving certain disturbances of 
nutrition of which the most characteristic are myxedema and cretin- 
ism. The results obtained from its use in these states are extraordi- 
nary, and it is to be regarded as a specific. Its use is based upon the 
fact that in cases of myxoedema the thyroid gland is usually found 
atrophied, and upon the discovery by Reverdin, Kocher, Schiff, Fuhr, 
Horsley, Crede, Zesas, and others, that extirpation of this gland pro- 
duces myxcedema or a train of symptoms practically identical with it. 

It is customary to employ the desiccated thyroid gland (Thyroidum 
Siccum) in a powdered form, or made into a tablet or placed in a 
capsule, in place of the raw gland itself. The dose of this is 1 grain 
(0.06) three times a day, which dose is gradually increased as the 
patient becomes accustomed to it. Although the remedy when 
first employed is given in the dose of about 1 grain (0.06), it may 
be rapidly increased a grain a day until about 6 grains (0.4) a day 
are reached, when a halt is made and the effect of this dor ; watched 
for some days. If the patient does not manifest symptoms cf overdose, 
on the one hand, or if he fails to improve on the other, then (re dose may 
be still further increased. No more than 15 grains (1.0) cf the dried 
gland should be given each day, and this quantity should be divided 
into several doses. 

Thyroid gland has been used very largely in the treatment of cre- 
tinism with success only second to that attained in the therapy of 
myxcedema, and with asserted success in dwarfism, excessive obesity, 
psoriasis, and scleroderma. After marked improvement or apparent 
cure has been effected by the treatment, it is necessary for the patient to 
continue using thyroid extract indefinitely, for if it is discontinued the 
myxcedema returns. The remedy may be given in minute daily doses 
or in full doses for several days at the end of every three weeks or a 
month. Though the latter plan is the more disagreeable, it is asserted 
33 



514 DRUGS 

to possess a greater therapeutic and preventive value. The rapid 
growth of cretins under thyroid gland therapy may lead to bending 
of the bones, and care should be taken that too much exercise on the 
feet is prevented. When used in obesity, an increased amount of 
nitrogenous food should be supplied to prevent loss of strength, as 
this gland causes increased catabolism not only in the fatty, but also 
in the proteid parts of the body. Under its influence the body can- 
not assimilate glucose if it is ingested in full doses, and glycosuria 
develops. In obese diabetics the gland is probably a dangerous drug 
for this reason. In the author's experience its effects are inconstant 
in obesity. It benefits some patients and is useless in others. 

Because of the very great effect of this gland upon nutritional 
processes it has been employed in a host of ailments in which there 
has been no prospect of producing good effects. Among these, how- 
ever, some experiments have resulted so favorably that the use of the 
gland has received recognition, although we do not understand exactly 
how it does good. Thus in the dose of from 5 to 20 grains (0.30-1.3) 
three times a day, according to the degree to which it produces its 
effects, it has proved of value in acute mania and melancholia, puerperal 
and climacteric insanities, and in stuporous states with primary dementia. 
The treatment should be persisted in for at least thirty days, according 
to Mabon and Babcock. Recently the use of full doses of thyroid 
gland has been strongly recommended for the prevention and relief 
of the early symptoms of eclampsia on the ground that it relaxes the 
renal bloodvessels, increases urinary flow, and also increases the elimi- 
nation of urea. 

Thyroid gland given in the dose of 5 grains (0.3) in the early morning, 
followed by quiet and, if possible, by sleep, sometimes relieves the 
vomiting of pregnancy. A dose may also be given at bedtime. Given 
during the last weeks of pregnancy it may be employed to ensure a flow 
of milk in women who have had no secretion after previous pregnancies. 

It has also been asserted that thyroid therapy is useful in the treat- 
ment of exophthalmic goitre, but this is positively untrue, and it may 
seriously injure such a patient, since in overdose the gland causes 
symptoms like those of exophthalmic goitre. 

Thyreoiodine and iodothyrine have been introduced as representing 
the therapeutic activity of the crude gland; but while they possess 
some action, they cannot be so used with the expectation of such good 
results as when the desiccated thyroid gland itself is resorted to. 

In the B. P. the dried gland (Thyroideum Siccum) is also official, 
as is the Liquor Thyroidei, dose 5 to 15 minims (0.3-1.0). 

Untoward Effects. — Overdoses of thyroid produce violent headache, 
feeble action of the heart, and sometimes diarrhoea and vomiting. 
Should any of these symptoms come on, they are an indication for the 
complete stoppage of the use of the drug for some days, and a return 
to its use must be gradual. These symptoms can be avoided by 
cautious dosing and by keeping the patient in bed for some days 
after the treatment is inaugurated. 



TRIKRESOL 515 

Under the name thyroprotein Beebe has prepared a concentrated 
extract assayed and adjusted so that it contains a standard amount of 
iodine (0.33 per cent.), which is used as a substitute for thyroid extract 
in tablets made up of thyroprotein and lactose in the strength of 1, 2, 
and 3 per cent. each. One tablet is given once to thrice a day. 

THYROIDECTIN. 

Under this name the dried serum of animals which have been subjected 
to thyroidectomy is used for the relief of exophthalmic goitre or Graves' 
disease. The theory is that as a result of removing the thyroid gland 
in the animal a state is produced in which the serum lacks the normal 
content of thyroid secretion , and when this serum is given to a patient 
suffering from Graves' disease it unites with the excess of thyroid 
secretion in the patient's blood and so diminishes or antidotes its effect on 
the body. Under the name of " Antithyroidin" the liquid serum is given 
in the dose of 10 to 75 minims (0.65-5.0) in milk. Under the name 
of "Rodagen" the dried milk of thyrodectomized goats is given in 
similar cases in the dose of 1 to 4 drachms (4.0-16.0) daily. Thy- 
roidectin is prepared in this country, Dose, 5 to 10 grains (0.3-0.6) 
t. i. d. 

TRICHLORACETIC ACID. 

Acidum Trichloraceticum, U. S., is a compound of chlorine and acetic 
acid, occurring in deliquescent crystals, and used as a rapid, active 
escharotic upon venereal and other icarts. A peculiarity in its effect 
is that it produces a dry scab which speedily falls off, leaving a heal- 
ing surface beneath. It is also claimed that its action is not followed 
by secondary inflammation and pain. It may be used by applying a 
crystal to the wart or other growth, and protecting surrounding parts 
with collodion, or else it is applied in liquefied form by using a glass 
rod and rubbing it into the part. 



TRIKRESOL. 

Trikresol is a combination of ortho-, meta-, and paracresol, bodies 
allied to creolin and phenol. Trikresol appears in commerce as 
a white liquid, smelling somewhat like creosote, and soluble in water 
in the proportion of about 2\ per cent. It forms a clear solution, 
and does not benumb the skin as does phenol. It is also much 
less irritant and less poisonous than phenol or bichloride of mercury. 

Therapeutics. — Trikresol is used as an antiseptic in surgery in 1 
per cent, solution. In the strength of 1 : 1000 to 1 : 500 it may be 
employed as an antiseptic collyrium in ophthalmic practice, in which 
field it has proved very useful. 



516 DRUGS. 

TRIMETHOL. 

Trimethol is a benzene derivative of trimethyl-methoxy-phenol. It 
is said to be fifty times as efficient as phenol as a germicide and when 
taken by the mouth the claim is made that it passes through the 
alimentary tract unabsorbed. For these reasons it has been employed 
for the relief of intestinal disorders due to the presence of pathogenic 
organisms as in so-called intestinal intoxication and infantile diar- 
rhea. Its tendency is to be somewhat constipating. Trimethol is 
administered in tablets containing 1| minims (0.08), the dose being 
about 4 tablets three times a day when given to adults, and in syrup 
each drachm (4.0) of which contains f minim (0.045). The dose of the 
syrup is J to 1 J drachms (2.0-6.0) to an infant and 2 to 3 drachms (8.0- 
12.0) to a child, well diluted with at least four times as much water. 
The drug is 3aid to be non-toxic and not incompatible with other drugs. 

TRIONAL. 

Sulphonethylmetfianum, U. S., and Methylsulphonal, B. P., or trional, 
is related, both chemically and therapeutically, to sulphonal, and is 
practically identical with that drug in its effects on the general system. 
It occurs in shining, odorless, colorless plates with a very faint, bitter 
taste, and is soluble in 200 parts of water. Trional is used for the 
relief of insomnia of a functional type, and the sleep produced ordinarily 
ensues in about twenty to thirty minutes after the drug is taken, and 
lasts five to six hours. The dose is 15 to 30 grains (1.0-2.0). Doses 
larger than 15 to 30 grains should never be given continuously, and it 
is always a good plan after the drug has been given for five or six 
consecutive days to stop its use for two or three days. It is well to 
order for the patient who is taking trional one of of the saline purgatives 
daily, particularly if there is any tendency to constipation. 

Trional is slightly soluble in water and very soluble in alcohol. 
Advantages in its use are lack of disagreeable taste and the absence 
of symptoms of circulatory depression. The best way to administer 
trional is in hot broth or tea or whisky. It is wise to decrease gradu- 
ally the dose if the drug is taken night after night. Like sulphonal, 
trional is apt to make the patient drowsy the day after its ingestion. 

When trional is taken in full dose for several weeks, it produces 
alterations in the blood which are manifested by hsematoporphyrinuria 
— a state in which the urine is dark red or almost black. The drug 
should be stopped at once when the urine becomes red and saline 
purgatives must be used freely. There are no characteristic symptoms 
of trional-poisoning save profound coma. The pupils are not con- 
tracted as in opium-poisoning. 



TROPACOCAINE. 517 

TROPACOCAINE. 

Tropa cocaine is a vegetable alkaloid derived from Coca Erythroxylon 
as is its sister alkaloid cocaine. It is found in larger proportions in coca 
grown in Java than in coca grown in Peru. It is only half as toxic as 
cocaine. In water it forms a neutral solution, and its solutions can be 
sterilized by boiling. Almost its sole use in medicine is for the induc- 
tion of spinal anaesthesia when injected into the subarachnoid space. 
For such use it is best obtained in sterile glass ampoules containing 
about 20 minims (1.3) of 25 per cent, solution, that is, about 1 grain 
(0.06) of the drug. This is the dose for a strong, well-developed man. 
For the aged and feeble 10 or 15 minims (0.05-1.0) is sufficient. The 
method is eontraindicated in persons with a low blood-pressure. 

The method of inducing spinal anaesthesia is as follows: If the patient 
is strong he sits on the edge of the operating-table, with his feet on a 
chair and with his body bent forward as far as possible to separate the 
intervertebral spaces. If the patient is too feeble to sit up, or there are 
other reasons for the prone posture, he lies on his side with the back 

Fig. 65. 




A, Space between the third and fourth lumbar vertebrae for subarachnoidean injection (Quincke's 
area) ; B, area of puncture suggested by Turner. 

flexed and the knees drawn up as far as possible. The skin from the 
first to the last lumbar vertebra is sterilized with tincture of iodine, and it 
may be anaesthetized by Schleich's infiltration method. (See Cocaine.) 
A strong hollow needle, reinforced by a stylet in some cases, is then in- 
troduced a little to one side of the middle line at different levels accord- 
ing to the area it is desired to anaesthetize, but never above the tenth 
dorsal interspace, as there is danger of injuring the cord. It usually 
enters the subarachnoid space at a depth of -4 to 6 Cm., according 
to the size of the patient. When introduced in the lumbar region 
the direction of the needle is almost at a right angle to the plane of the 
back, but directed slightly upward. In the dorsal region this upward 



518 DRUGS. 

tendency is increased so as to conform to the overlapping of the spinous 
processes. If the puncture is successful on withdrawing the stylet, 
cerebrospinal fluid escapes from the needle in drops or jets. If the 
tap is dry the needle may be plugged by tissue, it may have failed to 
enter the space, or it may have been carried across the space and be 
embedded on the other side. The re-introduction of the stylet may 
remedy the first fault, pushing the needle farther may correct the 
second difficulty or, withdrawing it, may disengage the tip from the tis- 
sues on the far side from the puncture. If these moves fail another 
puncture must be made. If the needle is dripping fluid a syringe is 
attached to it, and a little cerebrospinal fluid is sucked into it to warm 
the syringe and to dilute the contents of the ampoule of tropacocaine 
solution which has been-drawn up into the syringe. The injection should 
be slowly made. When the area to be anesthetized is that of the lower 
limbs and trunk up to the navel the injection is made at the third or 
fourth lumbar level, and this area can be increased to the nipple by tilt- 
ing the body so that the fluid is diffused upward. When the upper 
abdominal area is to be anaesthetized the tenth or eleventh dorsal space 
is selected. A good localizing point is made by drawing a line across 
the back from the iliac crests. This corresponds to the space between 
the third and fourth lumbar vertebra? . Within a few moments the 
legs feel asleep and numb and the patient is ready for operation almost 
at once. The site of operation is shut off from vision by a hanging sheet. 

If the patient is very apprehensive a hypodermic injection of 
scopolamine and morphine may be given before the puncture is 
made. Severe headache lasting for days is the most common un- 
toward effect. Vomiting seems to occur in about 7 per cent, of 
cases. Age does not seem to contraindicate the method at either 
extreme of life. Apparently, it is not contraindicated as strongly as 
ether or chloroform when the heart, lungs, or kidneys are diseased or 
when diabetes is present. Indeed, it seems safer than these drugs in 
profound asthenia. The patient should rest in bed for several days 
after the injection. 

Notwithstanding the claims of its advocates, spinal anesthesia is 
not very widely practised. It is statistically more dangerous than 
chloroform, for in 15,842 cases collected by Strauss there were 21 
deaths, or 1 in 754. The method is to be used in certain peculiar 
cases, but not as a general procedure. 

TUBERCULIN. 

Tuberculin is prepared in several ways which vary widely, but the 
product is, to all intents and purposes, the same as to its effects, although 
it may vary as to its strength and applicability. It occurs in several 
forms as follows: 

Old Tuberculin (O. T.) is made from human tubercle bacilli grown 
on bouillon with 5 per cent, of neutralized glycerin. The bouillon 



TUBERCULIN. 519 

is boiled until concentrated to one-tenth its volume and then 50 per 
cent, of glycerin is added. It is then filtered to rid it of bacilli. 
It is chiefly used for diagnostic purposes (see below). Its diagnostic 
hypodermic dose is -^ to 1 mg. Its therapeutic dose 10 q 00 to yqoo m g- 

Bouillon Filtrate (B. F.) Tuberculin is made as is Old Tuberculin, 
except that it is not concentrated and not diluted with glycerin except 
to the extent of 5 per cent. The only protection from living bacilli 
being in it is the filter, as there is no boiling. It is not used for 
diagnosis. Its therapeutic dose is 10 q 00 to -^wo m g- ^ * s sometimes 
called Denys' Tuberculin. 

Tuberculin T. R. or Tuberculin Residuatum, is made by growing, 
evaporating to dryness in vacuo, and grinding the bacilli. The 
ground residue is then dissolved in salt solution and centrifuged. 
The centrifuged residue is again dried, ground, and dissolved 
repeatedly until the final addition of salt solution makes a clear fluid. 
Its therapeutic dose is 10 q 00 to 50 1 00 mg. This is the tuberculin most 
used for therapeutic purposes. 

Tuberculin B. E. (Bacillen Emulsion) is prepared by pulverizing 
and suspending in glycerin solution tubercle bacilli. Its therapeutic 
dose is - 1Q q Q0 - to y^- mg. for therapeutic purposes. 

It is important to remember that 1 mg. of Old Tuberculin and of 
Bouillon Filtrate is not identical with 1 milligram of Tuberculin 
Residuatum or Bacillen Emulsion. The former do not contain any 
tubercle solids, they are only solutions in which the bacilli have 
grown, whereas in the case of Tuberculin Residuatum and Bacillen 
Emulsion the actual solids, made by grinding of the bacilli, are 
present in solution or suspension; that is, 1 milligram of tubercle 
bacilli solids weighed after drying. They are, therefore, more 
accurate preparations. 

Physiological Action. — Although the products of the processes just 
described differ in their physical appearances and in their strength, the 
effects following the injection of any one of them into the human body 
is a difference in degree rather than in kind. While the filtrates have 
been supposed to exercise an antitoxic effect and the emulsions an anti- 
bacterial effect, there is no scientific proof of value to support this belief, 
and it is now well recognized that as the tubercle bacillus does not 
secrete or make a toxin, the word antitoxic, in the ordinary acceptation 
of that term, cannot be employed. On the contrary, the object of 
employing tuberculin, whatever its form, for curative purposes is to 
stimulate the protective processes of the body. To illustrate this, the 
following experimental result maybe cited: If a guinea-pig is inocu- 
lated by the tubercle bacillus the point of inoculation speedily heals, 
but about two weeks later breaks down and a persistent ulcer forms. 
If, however, the animal has been inoculated on a previous occasion, the 
second spot becomes red within a few hours, soon breaks down and 
ulcerates, and then speedily heals. Furthermore, the nearby lymph- 
nodes do not enlarge as after a primary inoculation. In other words, 



520 DRUGS. 

the primary inoculation has enabled the animal to overcome the second 
one. 

It is to be remembered that tuberculin in any dose is not in itself 
capable of exercising an influence upon a healthy person, but only 
acts if an individual is rendered hypersensitive by reason of the fact 
that he is tuberculous. In such persons it is supposed that various anti- 
bodies or lysins are formed which split up tuberculin and so form a poison 
to which the cells of the body react, this change taking place not only 
to the tuberculin injected, but in the tuberculin formed by the bacillus 
which has infected the patient's body. It is to be remembered, then, 
that when injected in full dose into a healthy man tuberculin has 
no action, but when injected into a tuberculous man it has a very 
powerful effect, which varies with the dose and the ability of the patient 
to react. This effect consists in local and general manifestations. 
At the point of injection there is hyperemia, swelling, heat, and sore- 
ness. At the area of tuberculous infection there is a similar state. 
If this area is visible it is seen to be red and hypersemic. If this area is 
in the lung, rales often develop where before nothing but slight dulness 
on percussion and tubular breathing were present. The general effect 
consists in a train of symptoms closely resembling those of epidemic 
influenza. There is pain in the bones, headache, general malaise, 
and more or less well-marked febrile movement, often preceded or 
accompanied by a chill and sweat. The pulse is quickened and the 
patient may, if the reaction be severe, feel exceedingly ill and weak 
for a period varying from a few hours to even as long as two weeks or 
more. 

Therapeutics. — When used for treatment, tuberculin is not employed 
as a direct curative agent, but as one which will stimulate the pro- 
tective processes of the body to overcome the invading micro-organism. 
Different methods are employed in its administration. Some give it 
in such large doses that the patient suffers from more or less reaction, 
but the best method is that in which such infinitesimal doses are 
given that there is no reaction in the coarse sense, but only stimulation 
of the protective processes. As the patient improves, larger and larger 
doses may be given to still more stimulate these processes, but the 
greatest care is to be used never to cause reaction. 

Tuberculin is never to be used for treatment or diagnosis if the 
patient is febrile, or so feeble that he cannot react. Acutely ill or far- 
advanced feeble cases are, therefore, not suitable to its use. Rapid 
results are not to be expected. This plan of treatment must often be 
used as long as a year before it may be considered as fairly tried. 
Manifestations that the patient is improving are a diminution of the 
symptoms of his disease and a gain in weight. 

I am strongly of the opinion that tuberculin should be used for treat- 
ment only by those who have had special training in its use. More 
harm than good follows its employment by the general practitioner. 

Cooke, of London, makes this comprehensive statement which I 



TUBERCULIN. 521 

heartily endorse: "The system of dosage and the method of increase 
cannot be learned or acquired by reading from a text-book; and, as a 
matter of fact, no book could be written with any degree of accuracy 
on this part of the subject. It is a question of personal experience, 
and that can only be acquired by personal attendance at a properly 
conducted tuberculin dispensary several hours a week over several 
months." 

Administration. — In the treatment of tuberculosis by tuberculin 
it is always given hypodermiVally and usually into the subcutaneous 
tissues, not the muscles, of the back. It is best to use a specially 
devised tuberculin syringe graduated in hundredths of a cubic centi- 
meter. It must be borne in mind that patients vary greatly in the dose 
which they can take. Each case is a law unto itself, and, in order to 
avoid disagreeable effects, the initial dose should be exceedingly 
small and in the nature of a " feeler." Further, it not infrequently 
happens that if no visible reaction follows the first dose, it develops 
after the next one, so the second dose should not be greater than the 
first, nor should the dose be increased until there is enough evidence 
to justify the belief that this can be safely done. The site of the last 
injection should always be carefully examined to discover if it is 
indurated or tender. If it is, this sign of local reaction warns against 
larger doses until this local irritation ceases to exist. So, too, if there 
is present a febrile movement, even if it be only a few fractions of 
a degree, the dose should be postponed. Reaction to an injection 
usually develops within a few hours of the injection at the latest. If 
fever comes on as late as forty-eight hours, it is probably due to another 
cause. If by an error a reaction has ensued, the treatment must stop 
for a period of at least ten days to two weeks after all signs of it have 
ceased, and, on renewing the treatment, the dose should be much 
smaller than the one that induced the disagreeable symptoms. The 
ordinary rules of strict cleanliness are to be followed as to the injection. 
If they are, there is no danger of local sepsis. 

Dosage. — The dose varies, as already stated, according to which 
tuberculin is to be used for therapeutic purposes. When tuberculin 
is employed for treatment the initial dose is usually x q mg., but 
if the patient is not in good condition, less than this, i. e., toVo or m &- 
If this small dose is well borne, the dose may be doubled, but when, 
by the process of doubling, the dose reaches thousandths or hun- 
dredths of a milligramme, very great care must be used in making a 
further increase. The smaller doses may be given twice a week; the 
larger ones are usually employed once a week. T. R. and B. E. are 
now placed on the market by the best manufacturing pharmacists, 
in the form of hypodermic tablets, which are the best, as they are more 
convenient, and in small glass vials, hermetically sealed, usually con- 
taining 1 mil. of tuberculin solution, equaling 1 milligramme of dry 
tubercle solids. If to -^ mil. (0.1 mil.) of this solution is added 100 
mils, of sterile salt solution, 1 mil. of this dilution will, of course, equal 



522 DRUGS. 

one one-thousandth of a milligramme, T oVo ' an d if 1 mil. of this dilution 
is diluted by 10 mils, of salt solution, each cubic centimeter will equal 
one ten-thousandth of a milligramme, 10 q 00 ; or, to put it differently, 
Yq mil. (0.1 mil.) of the dilution made by adding 100 mils, of salt 
solution to one-tenth of the original package will equal 10 o 00 mg. 
The balance of the dilution so made is always thrown away unless 
other patients can receive simultaneous doses, as it decomposes; that 
is, the dilution decomposes if kept for any length of time. 

Diagnosis. — When old tuberculin is used for diagnostic purposes the 
physician uses a dose which is large enough to cause a definite reaction 
if tuberculosis is present In other words, he expects the injection to 
be followed by a rise of temperature and a certain degree of malaise 
and discomfort if the patient is infected by this particular bacillus. 
This diagnostic dose is, therefore, far larger than that employed for 
the purpose of increasing the patient's resistance. It usually amounts to 
from T V to 1 milligramme (0.0001-0.001), according to the condition of 
the patient. If he is feeble, the smaller dose is the one of choice. The 
reaction, if the patient is tuberculous, develops in about four to twelve 
hours, and lasts from twenty-four hours to several days. If no reaction 
follows the first dose, gradually increasing doses are used, up to 5 milli- 
grammes or even more. Not only are general symptoms present, but at 
the site of the injection the parts are reddened and local lesions of tuber- 
culosis show inflammatory changes. The test is not to be employed 
in febrile patients, that is, those whose evening temperature exceeds 
99° F. It is also to be recalled that occasionally those who are not 
tuberculous give a positive reaction if they are old syphilitics. Tuber- 
culous lesions long since healed, and in no way responsible for the 
present ill health, may do likewise. It also fails to cause a reaction in 
a small proportion of tuberculous cases. The test is not, therefore, 
infallible. 

Although those who have studied the reaction following the hypo- 
dermic use of tuberculin tell us that, when properly used, it is not 
dangerous, there is, nevertheless, a feeling among the majority of the 
profession that the reaction may be injurious to the patient. This 
has been the attitude of the author ever since tuberculin was first 
introduced as a diagnostic agent. When a patient presents sufficient 
physical signs or other symptoms to lead the physician to the belief 
that he is probably tuberculous, it is better to treat him as a tuberculous 
case, since under these circumstances no harm can be done, and if not 
tuberculous he is certainly in a fair way to become so, the impaired lung 
being a ready field for the growth of the tubercle bacillus should it 
enter the chest. Do not forget the wise saying, "the use of tuber- 
culin in diagnosis is like looking for a gas leak with a lighted 
match." 

The ophthalmo-tuberculin test is prepared by dropping into a healthy, 
never into an inflamed, eye a small amount of tuberculin. This is 
now placed on the market in discs or tablets containing the amount 



PLATE I 






Positive Tuberculin Skin Reaction of von Pirquet. (Hamill.) 

Tiie middle spot, where there is no redness, shows the effect of 
scarification without tuberculin. 



PLATE 111 



Tuberculin Skin Reaction of Mora. (Hamill.j 

Upper irately severe reaction. Lower figure, severe rea 

Lin was ru 



TUBERCULIN. 523 

necessary. This dose is dissolved in five drops of water, which is then 
dropped into the conjunctival sac. Within three to twenty-four hours 
a more or less sharp conjunctivitis develops, ranging from a slight 
inflammation to a purulent condition. If the test is negative and it is 
desired to repeat it, the procedure must take place in the opposite eye, 
because the tissues of the first eye have been sensitized and will give a re- 
action even if no infection by the tubercle bacillus exists elsewhere. 
The test fails, for some unknown reason, in a small proportion of cases 
which are actually tuberculous. 

It should be stated as to the ophthalmo-tuberculin reaction that the 
majority of ophthalmic surgeons are now distinctly opposed to the 
general employment of this test, since there are a number of cases on 
record in which very violent and even disastrous changes have ensued. 

The skin test by the use of tuberculin is in two forms, that of von 
Pirquet and that of Moro. In the von Pirquet test the skin of the arm, 
leg, or abdomen is scarified at three or four spots, as in vaccination. In- 
to one of these spots a few drops of pure water and glycerin are gently 
rubbed to act as a control spot. Into the other spots is rubbed a few 
drops of old tuberculin solution (O. T.), which comes put up in 
small glass tubes like those containing glycerinated vaccine lymph. 
In from twelve to thirty-six hours it will be found, if the patient is tuber- 
culous, that the spots treated with tuberculin have a reddened areola 
and are crusted as compared to the control spot. This test is so fre- 
quently positive in seemingly healthy adults that it loses much of its 
value in this class of patients. In young children it is significant. If 
the patient is far advanced in tuberculosis no reaction ensues. 

The Moro test consists in using an ointment composed of 5 mils, of 
old tuberculin with 5 grammes of anhydrous lanolin. This ointment 
should be freshly prepared or, if kept for any time, should be preserved 
in a refrigerator. Ten grammes of ointment is sufficient for 100 tests. 
A small piece of the ointment about the size of a pea is rubbed into the 
skin of the abdomen or of the chest near the nipple. If the patient is 
tuberculous, a typical reaction develops in the area to which the oint- 
ment has been applied, and consists in the appearance of more or less 
numerous papules which are preceded by an erythematous rash. This 
rash develops in about twelve to twenty-four hours, but sometimes 
not until forty-eight hours have elapsed. It reaches its acme in most 
cases at the end of forty-eight hours. It possesses the great advantage 
of being entirely without danger to the patient, and in the avoidance 
of the nervous perturbation which is sometimes caused by the scratch- 
ing of the skin in the von Pirquet method mentioned above. The 
test loses its positive value in adults, or, to express it otherwise, a 
number of adults who are not actively tuberculous nevertheless pre- 
sent the reaction. 

This ointment is now placed on the market in 2-gramme collapsible 
tubes. 



524 DRUGS. 



TURPENTINE. 



Much confusion often exists in students' minds as to the difference 
between oil of turpentine (Oleum Terebinthince, U. S. and B. P.) and 
spirit of turpentine, both of which are the same substance under a 
different name. This oil is not, however, the same thing as "tur- 
pentine," for the oil is distilled from turpentine. The distilled oil 
is a thin, clear fluid having a peculiar odor and taste, and is irritant 
to the skin and mucous membranes. It is exceedingly inflammable, 
should never be placed near a light, and if added to any strong mineral 
acid takes fire. 

When turpentine is spoken of in this book as a therapeutic agent, 
the doubly distilled oil of turpentine {Oleum Terebinthinoe Rectificatum, 
U. S. and B. P.) is what is meant unless the contrary is stated. 

Physiological Action. — Turpentine when taken internally produces a 
sense of warmth in the stomach, a quickened pulse, a warm skin, 
and slightly accelerated breathing. In overdose it may cause intoxi- 
cation. Upon the circulation it produces a very slight rise of arterial 
pressure, increased pulse-rate, and increased heart-force. On the 
nervous system the drug, in large amounts, causes loss of sensation 
before it affects voluntary motion. 

The drug is eliminated by the kidneys and lungs, and gives the 
odor of violets to the urine. 

Poisonous doses cause strangury, bloody urine, renal inflammation, 
and cyanosis, with dilated pupils and gastro-enteritis. 

In persons with an idiosyncrasy to this drug, erythematous, papular 
or vesicular eruptions may follow its external or internal use. 

Therapeutics. — External Use. — Turpentine is used as a local 
application for the purpose of producing counterirritation over any 
area where deep-seated inflammation exists. Under these circum- 
stances it is almost always used in the form of a stupe, made as fol- 
lows: Place a tin cup containing the turpentine in a vessel containing 
hot water, so that the turpentine may be warmed without coming near 
a flame. Dip a piece of flannel into very hot water and wring it out 
in a twisted towel, and when it is so dry that no water drips from it, 
dip it into the hot turpentine and wring it out again to free it from 
any excess of the drug. The cloth, while hot, should be applied and 
allowed to remain until discomfort ensues, when it should be with- 
drawn, as it will blister the skin if left on too long. Children and 
adults suffering from bronchitis may be rubbed on the chest with tur- 
pentine with much relief, but it should be diluted with sweet oil, half 
and half, or even two-thirds of oil, particularly if the patient is a child. 

Internal Use. — Turpentine is used internally as a stimulant of 
a diffusible type in the course of the exhausting fevers, particularly 
if flatulence exists or if ulceration of the bowels is present. In typhoid 
fever turpentine stupes, turpentine enemata, and the administration 
of the drug by the mouth are the best ways to overcome tympanites. 
At the end of the second week, when the tongue is red, dry, cracked, 



TURPENTINE. 525 

and brown, the teeth covered with sordes, and tympany -is well marked, 
turpentine may be used in emulsion in the dose of 5 to 10 minims 
(0.3-0.60) three times a day with advantage. Again, in convalescence 
from typhoid fever, when diarrhoea is persistent and due to an 
unhealed state of Peyer's patches, turpentine is the remedy par excel- 
lence. 

In intestinal and other passive hemorrhages, such as menorrhagia 
or hematuria, the drug is often of service. 

For the removal of a tape-worm, turpentine is given in the dose of 
J to 1 ounce (16.0-30.0), mixed with an equal amount of castor oil. 
This treatment is a somewhat dangerous practice, but is efficient. 
In chronic and well-advanced kidney disease large doses of powerful 
diuretics are often required to stimulate the kidneys sufficiently to in- 
crease urinary flow, and turpentine may be used under these circum- 
stances; but it is contraindicated if any acute irritation is present, 
as it may under these conditions produce suppression. 

Turpentine is contraindicated in the presence of any acute inflam- 
mation of the gastrointestinal tract and in acute nephritis. 

In lumbago the dose of 2 minims (0.12) is said to be very useful, 
and many have found the vapor of turpentine of value in bronchitis of 
a subacute or chronic type when inhaled from boiling water. (See 
Inhalations, Part III.) In gleet it is given by the mouth to stimulate 
the genito-urinary tract. Turpentine has been found of value in the 
treatment of purpura hemorrhagica. 

Administration. — Turpentine may be given for the relief of flatu- 
lence by placing 5 minims (0.3) on a piece of sugar, or in emulsion 
(Emulsum Olei Terebinthinw, U. S.) dose \ to 2 fluidrachms (2.0-8.0). 

A more agreeable preparation, not to be used in typhoid fever, is 
that recommended by Bartholow, as follows: 

1$ — Olei terebinthinae f 5j (4.0). 

Olei amygdalae expressi fgss (16.0). 

Tincturae opii f 5ij (8.0). 

Mucilaginis acacice f5v(20.0). 

Aquae laurocerasi fgss (16.0).— M. 

S. — A teaspoonful (4.0) every four hours for tympanites. 

When used as an enema the following is useful: 

Ifc— Olei terebinthinae fgj (30.0). 

Olei olivse f giss (45.0). 

Camphorse gr. xx (1.3). 

Mucilaginis acacise f gss (16.0). 

Aquae f §x (300.0).— M. 

S. — To be injected as an enema for the relief of tympanites and to aid in the 
removal of hardened feces. Stir thoroughly before using 

The author most commonly employs turpentine in enema by adding 
it to milk of asafcetida, 1 to 2 drachms (4.0-8.0) to 6 ounces (180.0). 

The liniment of turpentine (Linimentum Terebinthinae, U. S. 
and B. P.) is largely used as a stimulating application to sprains and 
enlarged joints. 



526 DRUGS. 

Turpentine applied with a brush to the part affected is of service 
in ringworm. 

The ointment of turpentine is used as a counterirritant and stimu- 
lant to the part to which it is applied. 

A mixture of turpentine and soapsuds is efficient in destroying bed- 
bugs. 

The following preparation is also official in the B. P.: Linimentum 
Terebinthince Aceticum. 

UROTROPIN. 

(See Hexamethylenamine.) 



UVA URSI. 

Uva Ursi, U. S., bearberry, is the leaves of* Arctostaphylos Uva 
ursi, a widely distributed evergreen shrub. The drug is known in 
the B. P. as Uvce ursi folia. Its active principle is arbutin, some- 
times called ursin. 

Therapeutics. — Uva ursi is employed in medicine as a weak, astrin- 
gent diuretic, possessing alterative power over the genito-urinary appa- 
ratus. It is used in pyelitis, cystitis, and in chronic gonorrhoea or 
gleet. When taken in overdose it escapes from the body as hydro- 
chinone, making the urine dark-colored or black on exposure to 
the air. 

Administration. — Arbutin itself is often used in the dose of 3 to 5 
grains (0.20-0.30). The dose of the extract (Extractum Uvce Ursi, 
is 1 to 4 grains (0.06-0.25), of the fluidextract (Fluidextr actum Uvob 
Ursi, U. S.) is 2 to 4 drachms (8.0-16.0) three times a day. An infu- 
sion (Infusum Uv& Ursi) is official in the B. P., dose 1 to 2 ounces 
(30.0-60.0). 



VALERIAN. 

Valerian (Valeriana, U. S.) is the rhizome and rootlet of Valeriana 
officinalis, a plant of Europe, but cultivated in America. It is official 
in the B. P. as Valerianae rhizoma. Its active principle is apparently 
a volatile oil (Oleum Valerianae). It also contains valerianic acid. 

Physiological Action. — Valerian is a very feeble sedative to the 
nervous system, tending to produce nervous rest. In male cats it 
causes sexual excitement to a great degree, probably from its odor. 
When very large doses are given to man, it causes a sense of warmth 
in the stomach, a slightly quickened pulse, and sometimes nausea and 
vomiting. Still larger amounts produce purging and mental hebetude. 

Theiapeutics. — Valerian is used alone or in combination with other 
drugs to quiet nervous females and to relieve nervousness and insomr 



VERATRINA. 527 

nia. In hysteria it is often very serviceable, and combined with 
morphine it has been much used in the treatment of delirium 
tremens. 

Administration. — The ammoniated tincture (Tinctura Valeriana 
Ammoniata, U. S. and B. P.), is given in the dose of 1 to 3 drachms 
(4.0-12.0), \ to 1 nuidrachm (2.0-4.0), B. P. These are the best 
preparations for ordinary use. The infusion, which is not official, 
is given in the dose of a wineglassful, while that of the simple tincture 
(Tinctura Valeriana, U. S.) is 1 to 3 drachms (4.0-12.0). The dose 
of the oil (Oleum Valeriana?) is 2 to 4 minims (0.12-0.25). 



VALERIANIC ACID. 

Acidum Valerianicum is an oily, colorless liquid of a strong odor 
and burning taste, but is not employed in medicine except in the form 
of its salts, such as the valerianate of zinc, iron, quinine, or ammo- 
nium, all of which are employed, partly for their sedative effects and 
partly for their influence as tonics. 

The dose of Zinci Valeras is h to 3 grains (0.03-0.20), that of 
Quinine Valeras 1 to 3 grains (0.06-0.20), of Ferri Valeras 2 to 10 
grains (0.12-0.60), and of Ammonii Valeras 2 to 10 grains (0.12- 
0.60). Under the name of "the pill of the three valerianates" Goodell 
recommended the following in nervousness and hysteria: 

J$ — Quininse valerates, 

Ferri valeratis, 

Ammonii valerates aa3j(1.3). — M. 

Fiant pilulse No. xx. 

S. — One or two pills three times a day. 



VERATRINA. 

Veratrina, U. S. and B. P., is an alkaloid derived from the seeds 
of Asagraa officinalis, and occurs in a grayish powder, which if it 
enters the nostrils produces violent sneezing which continues for hours. 

Physiological Action. Nervous System. — Yeratrine has little effect 
on the cerebrum, but it excites the spinal cord and the voluntary mus- 
cles, thereby giving rise to tetanic or tonic convulsions, which are never 
clonic or epileptoid. The dominant action of the drug is paralytic, 
and the nervous symptoms just named soon give place to paralysis. 
The muscles lose their contractile power and the nervous centres are 
depressed. 

Circulation. — In poisonous dose the heart is slowed by the drug, 
greatly weakened, and finally stopped in diastole. After death the 
heart is found to be soft and flabby. In smaller doses it at first slows 
the pulse by stimulating the peripheral inhibitory nerves and the 



528 DRUGS. 

centres in the medulla, but later these parts are paralyzed. It first 
stimulates the vasomotor centre, then paralyzes it. 

Respiration. — The drug kills by failure of respiration, due to 
paralysis of the respiratory centres. 

Temperature. — Veratrine always causes a decrease in bodily heat. 

Poisoning. — The symptoms of poisoning in man are collapse, a 
pale, cold, wet skin, pinched features, and a rapid, thready pulse, 
accompanied by violent vomiting and muscular tremors. Tetanic 
convulsions may come on and resemble those of strychnine in that 
they arise from the slightest touch or draught of air; after death the 
muscles will be found to have lost their irritability. 

Therapeutics. — Veratrine is never used internally. It is employed 
chieflv in the form of an ointment rubbed into the skin over parts 
affected by muscular rheumatism and rheumatic joints and over neu- 
ralgic nerves. It should be used most carefully, as absorption of the 
drug may take place in sufficient quantity to poison the patient. 

VERATRUM VIRIDE. 

Veratrum Viride, U. S., Indian poke, poke root, or swamp hellebore, 
is an American plant largely used for the purpose of depressing the 
circulation and nervous system. Until recently it was official in the 
B. P. under the name of Veratri viridis rhizoma. 

It probably contains a number of principles, but at present our 
knowledge of the chemical constitution and physiological action of 
veratrum viride is in a state of chaos, because some of the European 
pharmacologists seem to confuse it with veratrum sabadilla, which 
contains veratrine as its active principle, whereas veratrum viride 
depends upon other ingredients for its effects. Confusion also exists 
as to the character of its active constituents. When H. C. Wood 
studied the drug, in 1874, he considered that viridin and veratroidine 
were its two chief principles. Viridin was probably an impure jer- 
vine, and veratroidine is of uncertain constitution. Salzberger has 
isolated an alkaloid which he calls protoveratrine. which is exceed- 
ingly poisonous. 

The Committee on Alkaloidal Assays of the American Pharmaceu- 
tical Association state that the constituents of veratrum are as follows : 
Protoveratrine, which is the most powerful and toxic; jervine, which is 
weak, although present in an amount about three times as great as 
protoveratrine; and rubijervine, which is so small in quantity and is 
so feeble in effect as to be almost negligible. Veratroidine, at one 
time thought to be an active principle, is now considered a mixture 
of amorphous bases. 

The same contradictions exist as to its physiological properties 
because of the confusion in the names of its principles, and because 
different pharmacologists have reported diametrically opposed results. 
Thus, the elder Wood taught that veratrum viride is a powerful cardio- 
vascular depressant, whereas the younger Wood reaches conclusions 



VIENNA PASTE. 529 

directly opposed to those of his father. The studies of the latter are, 
however, more nearly in accord with those of Houghton, and they all 
agree in asserting that veratrum viride greatly slows the pulse, prob- 
ably by stimulation of the vagi. The primary fall of arterial pressure 
may be due to this slowing of the pulse, and not to any depressant effect 
on the heart or vasomotor system, but the dominant effect of full 
doses is a fall of blood-pressure due to depression of the vasomotor 
centre. On the other hand, Pitcher and Sollman state there is no 
depression of the vasomotor system, but that the fall of pressure is due 
to the great slowing of the heart induced by stimulation of the vagus. 
Collins has recently shown that in man the drug decreases both sys- 
tolic and diastolic blood-pressure and causes a slowing of the pulse. 

Therapeutics. — Although pharmacologists are so divergent in their 
views as to the effect of veratrum viride, physicians of wide experience 
consider it of peculiar value in a number of states. Thus, many 
practitioners consider veratrum by far the best remedy in puerperal 
eclampsia. If given in this condition, the dose must be large, as 
much as 20 to 30 minims (1.3-2.0) of the fluidextract hypodermically, 
and followed by 5-minim doses until the pulse is reduced to the normal 
rate. These heroic doses are said to be absolutely necessary and not 
to cause any evil effects. Its use is indicated only in cases with high 
arterial tension, a bounding pulse, and suffused face. Under the 
name of Veratrone an excellent preparation of veratrum viride is used in 
eclampsia in the dose of 10 to 15 minims (0.6-1.0) by hypodermic 
injection. It is also of value in excessive cardiac hypertrophy and in 
the irritable heart of strong, healthy men. In aneurism, where the 
circulatory disturbance is great and the arterial pressure high, the 
drug may be used, with great care, to decrease the pressure and prevent 
rupture of the diseased vessel. 

Contraindications. — Veratrum viride is contraindicated in all 
conditions of depression or exhaustion, and if vomiting is feared. 

Administration. — A good preparation to employ is the tincture 
{Tinctura Veratri viridis, U. S.), dose 5 to 20 minims (0.3-1.3). 
The fluidextract {Fluidextr actum Veratri viridis, U. S.) is usually 
given in the nose of 1 to 3 minims (0.06-0.2). Under the name 
of Norwood's tincture a saturated tincture was at one time largely 
sold. It is not official, and ought never be used for this reason. 

VERONAL. 

(See Barbital.) 

VIENNA PASTE. 

Potassa cum cake is a milder and more manageable escharotic 
than is caustic potash, and is used for the same purposes. (See Potas- 
sium Hydroxide.) 
34 



530 DRUGS. 



WARBURG'S TINCTURE. 

Warburg's tincture is a complex liquid formed by the mixing 
together of no less than thirteen ingredients. Its inventor, Dr. War- 
burg, held its composition as a secret for a time, but finally made it 
public. Since he published the original formula it has been consid- 
erably altered, and some of the preparations now sold as Warburg's 
tincture probably contain none of the original ingredients. Further 
than this, some of these ingredients are now not obtainable. It ought 
to be made as follows, if possible: 

Aqueous extract of aloes 28 grains. 

Rhubarb 448 " 

Angelica-seed 448 " 

Elecampane 224 " 

Saffron 224 " 

Fennel 224 " 

Gentian 112 " 

Zedoarv-root 112 

Cubeb'. 112 " 

Myrrh 112 " 

White agaric 112 " 

Camphor 112 " 

Sulphate of quinine 1280 " 

Dilute alcohol enough to make 8 pints. 

The coarse vegetable portions of this list are to be ground into a 
coarse powder, and the myrrh and camphor, which have been pre- 
viously pulverized, added to them. The entire mass, less the quinine, 
is then digested for twelve hours in a well-covered vessel on a water- 
bath, the alcohol being prevented from evaporating as much as 
possible. The liquid is now to be strained under pressure and the 
sulphate of quinine added and dissolved. 

Therapeutics. — Warburg's tincture, next to pilocarpine, is the most 
powerful sweat-producer that we have, and possesses in addition 
remarkable antimalarial power. Its advantages rest in 'its favorable 
action where congestions accompany the malarial paroxysm. 

Administration. — To be of value Warburg's tincture should be 
given according to the following rules: The bowels of the patient 
should be first opened thoroughly by a saline purge, and \ ounce 
(16.0) of the tincture should be given in one dose undiluted, no other 
drink being taken. After the lapse of two or three hours a second J 
ounce (16.0) is given in the same way, and very shortly a profuse sweat 
appears, which often marks the crisis of the disease, and recovery 
soon takes place. 

XEROFORM. 

Xeroform, or tribromphenol-bismuth, is, as is seen from its second 
name, a combination of bromine, phenol, and bismuth. It was 



ZINC CARBONATE. 531 

introduced as a substitute for iodoform in surgical dressings. Its 
chemical constitution indicates that it possesses antiseptic properties, 
and its drying power and great volume enable it to render a wound 
antiseptic. As it does not contain iodine, it naturally lacks the 
peculiar virtues of iodoform, and, on the other hand, has none of its 
peculiar disadvantages. 



ZINC ACETATE. 

Zinci Acetas, U. S. and B. P., occurs in the form of white mica- 
ceous crystals, which are efflorescent and quite soluble in water. It 
acts as a decided astringent to the skin and mucous membranes, but 
is less astringent than the sulphate of zinc. It is used as a collyrium 
in eye diseases, such as conjunctivitis, in the strength of 1 to 2 grains 
(0.06-0.12) to the ounce (30.0). In gonorrhoea it is often employed 
instead of the acetate of lead in injections of the strength of 1 to 20 
grains (0.06-1.3) to the ounce (30.0) of rose-water. 

The treatment of poisoning by acetate of zinc is that adapted to 
gastro-enteritis. (See Gastro-enteritis, Part IV.) 

Chronic poisoning by zinc is very rare; the symptoms consist in 
muscular palsies, neuritis, and cachexia. 



ZINC CARBONATE. 

Precipitated carbonate of zinc {Zinci Carbonas Pr&cipitatus, U. S. ; 
Zinci Carbonas, B. P.) is used as a protective, rather astringent 
powder over surfaces affected by weeping eczema or other skin lesions 
accompanied by similar moist discharges. It may be employed to fulfil 
all the indications commonly treated by the oxide of zinc. It is very 
largely used, not as the precipitated carbonate, but as the impure or 
native carbonate, under the name of calamine. 

The following prescription is useful for moist eczema: 

I$— Calaminae 3j (4.0). 

Unguenti zinci oxidi 3vij (28.0). — M. 

S. — Apply to the eczematous spot. 

In cases of infantile intertrigo, or redness of the buttocks and geni- 
tals, from maceration, due to irritating feces, in infants suffering from 
diarrhoea, or where the urine is irritating, the following lotion is useful : 

1$ — Pulv. calaminae, 

Pulv. zinci oxidi aa 5ij (8.0). 

Glycerini 3iv (16.0). 

Alcoholis f§ij (60.0) 

Aquae q. s. ad Oj (480 mils.).— M. 

S. — Apply with a mop after each removal of the diaper and allow to dry. 



532 DRUGS. 

ZINC CHLORIDE. 

Chloride of zinc (Zinci Chloridum, U. S. and B. P.) is a white, 
crystalline, deliquescent powder of caustic taste and acid reaction, 
possessing considerable disinfectant power. It has been used as an 
eye-wash in the strength of 1 to 2 grains to the ounce (0.06-0.12: 
30.0), but is rarely so employed at present. The same solution may 
be used as an injection in the second stage of gonorrhoea. Small 
cutaneous cancers, particularly if near bloodvessels, may be advan- 
tageously treated by the following salve, which is efficacious and 
mummifies the tissues so that hemorrhage is prevented: 

1^— Zinci chloridi 5j (4.0). 

Pulv. amyli 3iij (12.0). 

Cocainse hvdrochlorat gr. xxx (2.0). 

Aquae destillat 5ij (8.0).— M. 

S. — Apply as a paste. 

Under the name of Liquor Zinci Chloridi, U. S. and B. P., is pre- 
pared a solution of the salt for disinfecting purposes of the strength 
of about 50 per cent. 

ZINC OXIDE. 

Commercial oxide of zinc (Zinci Oxidum Venale) is not used 
in medicine, but in the purified form is largely employed as Zinci 
Oxidum, U. S. and B. P., which is insoluble in water. In the form 
of the oxide-of-zinc ointment (JJnguentum Zinci Oxidi, U. S. and B. P.) 
this drug affords one of the most generally used applications in the 
treatment of skin diseases, burns, and sores. 

In all states where the surface of the skin is dry it is contraindi- 
cated, but where the eruption is moist it is useful. In the treatment 
of the chloasma of pregnancy the following prescription is of service: 

1$ — Zinci oxidi gr. iij (0.2). 

Hydrargyri ammoniati . « . . . gr. j (0.06). 

Olei theobromse ....... 3iiss (10.0). 

Olei ricini 3iiss (10.0). 

Essencise rosae gtt. x (0.60). — M 

S. — Apply to the face night and morning. 

In eczema with many vesicles — 

1$ — Pulveris camphorae . . . . . . 3ss (2.0). 

Pulveris zinci oxidi 3 iij (12.0). 

Glycerini gtt. xl (2.60). 

Adipis benzoinati §j (30.0). — M. 

S. — Apply to the part without other treatment or precede it by powdered bismuth, 

Unna's dressing (composed of gelatin 4 parts, water 10 parts, 
glycerin 10 parts, and zinc oxide 4 parts) is a useful application for 
ulcers and eczematous patches on the legs or arms. It is particularly 
useful for leg ulcers. The gelatin and cold water are put in a basin 
over a fire and a solution made; then the glycerin is added, and then 
the oxide of zinc is slowly added, with constant stirring. After the 



ZINC SULPHATE. 533 

mixture is complete it is poured into a can and allowed to cool, when it 
is ready for use. This application decreases swelling and is soothing 
and supporting. It is applied as follows: The part affected is well 
washed with water and soap, and then with alcohol. The paint 
having been warmed and melted, a large three-inch paint-brush is 
used to apply a coating to the limb all around the ulcer, and over this 
a single layer of gauze is applied. The gauze bandage should be two 
inches wide. The bandage must be laid on evenly and the ulcer 
covered by a pad of absorbent cotton. After one layer is applied it is 
cut and another coat of paint applied over it. Then another layer 
of gauze and another of paint are used, until several layers are in place. 
It is best to begin at the toes and work up toward the knee. All parts 
should be equally well covered. Finally the entire dressing is covered 
by a cotton roller bandage, which is removed in twenty-four hours, 
leaving what looks like a white rubber dressing on the limb. If the 
liquid from the ulcer oozes through the dressing profusely, a window 
is to be cut over the ulcer, and it can be locally treated by astringents 
or other measures. The patient should keep the limb elevated for a 
day or two, but can then walk with far more comfort than if a rubber 
supporting bandage is used. 

In powdered form zinc oxide is useful in the treatment of intertrigo 
and for conjunctivitis. Mixed with bismuth subnitrate and pepsin, it 
is largely used by some practitioners in the treatment of the summer 
diarrhoea of infants or adults. 

In the night-sweats of debility or of 'phthisis oxide of zinc in the 
following formula has been highly recommended, but the prescription 
probably depends largely for its action on the second ingredient : 

1$ — Zinci oxidi gr. xxx (2.0). 

Extracti belladonnse foliorum . gr. iij (0.20). — M. 

Fiant pilulse No. x. 
S. — One at night before going to bed. 

Bartholow recommended the oxide of zinc for asthma and whoop- 
ing-cough, given to an adult in the manner just indicated. 

ZINC SULPHATE. 

Zinci Sulphas, U. S. and B. P., is a white, somewhat efflorescent 
salt, of a sharp, acid taste, and soluble in water. In large amounts 
it acts as an irritant, and is employed as an irritant peripheral emetic 
in the dose of 10 to 30 grains (0.60-2.0). It is not so severe as sul- 
phate of copper in its emetic and poisonous properties, and may be 
repeated if the first dose does not produce vomiting. In weak solu- 
tions it may be used as an astringent application by injection in 
gonorrhoea and other affections of the urethral mucous membrane. In 
2-grain (0.12) pills it is sometimes given in serous diarrhoeas, particu- 
larly if it be combined with opium or minute doses of podophyllin -^ 
grain (0.001) at a dose. In conjunctivitis and other eye affections 
the drug is used in the form of a wash. (See Conjunctivitis.) 



PART III. 

REMEDIAL MEASURES OTHER THAN DRUGS — 
FOODS FOR THE SICK. 



ACUPUNCTURE. 



Acupuncture is a term applied to the deep insertion of a small 
pointed instrument into the tissues of any part of the body for the pur- 
pose of relieving pain, swelling, or dropsies. When used in painful 
affections it accomplishes its best results in lumbago and sciatica, 
particularly in the former. When treating lumbago in this manner 
the writer places two darning-needles in boiling water to render them 
aseptic, inserts them at right angles to the skin to the depth of one to 
one and a half inches, and allows them to remain in place for several 
minutes. They are then slowly withdrawn, care being taken to pre- 
vent their breaking. Often after this treatment the patient can at 
once move more freely, to his great delight. Ringer, with his usual 
clear clinical insight, has noted that this procedure is more successful 
in those who have bilateral pain than in those who have unilateral 
pain, and the writer has found this invariably true. 

In sciatica acupuncture is less successful than in lumbago, but 
sometimes gives relief. The needle should be inserted until it reaches 
the nerve, and, if possible, pierces its sheath, and it must be absolutely 
aseptic. Sometimes the best results follow from inserting the needle 
immediately below where the nerve finds exit from the pelvis. In 
other cases it is asserted that the insertion of a needle on the sound side 
over a spot corresponding to that which is painful may be beneficial. 
Acupuncture is useless in acute rheumatism and for the lumbar pain 
accompanying fevers. 

Sometimes a rhigolene spray may be used to freeze the skin over 
the parts with advantage in lumbago or sciatica. 

Acupuncture is occasionally resorted to for the relief of dropsy, 
but it is not commonly employed, although it is often a useful measure 
in this condition. When the skin of the limbs becomes so tense with 
an effusion as to endanger its life, the tension should be relieved 
by incisions, not punctures ; but saline purges are better for the 

(535) 



536 REMEDIAL MEASURES OTHER THAN DRUGS 

removal of dropsy, if they can be used. Punctures rapidly close and 
cause local indurations, while incisions remain open and permit free 
drainage. Immediately after the incisions are made the parts are 
to be dressed with cotton previously saturated with boric-acid solution 
and dried, or with absorbent cotton sterilized by baking in an oven. 
It is hardly necessary to point out that the incisions must be made 
with antiseptic precautions. (See Antiseptics and Dropsy.) 



ANTISEPTICS. 

The term "antiseptic," as generally used, does not necessarily 
imply the pow T er to destroy pathogenic germs. Any substance which 
inhibits the growth of micro-organisms, which destroys or renders 
innocuous the poisonous products of their action upon the tissues of 
the body, or which retards or prevents the absorption of such products, 
is properly termed antiseptic. 

Bichloride of mercury is efficacious as a germicide in a watery 
solution of 1 : 50,000. "Where albumin is present the bichloride 
is decomposed and rendered inert. The same change is observed 
when solutions are allowed to stand for some length of time, 
even when distilled water is used as a solvent. By the addition of 
either sodium chloride or a weak acid such decomposition is prevented. 
From this it follows that under ordinary circumstances solutions 
of bichloride should be freshly prepared, or, if it is desirable to keep 
them for a long time, a sufficient amount of sodium chloride should 
be added to prevent precipitation of the sublimate. Koch advised that 
as much salt should be added as would equal the weight of the sub- 
limate. Other observers, however, have advised ten times this weight 
of sodium chloride. 

Since bichloride solutions, when used in wounds or in cavities of 
the body, are brought in contact with blood-serum or other albumin- 
bearing tissues, care must be taken that the antiseptic powers 
of the mercury lotion are not destroyed by the neutralization 
of its active principle. The power of the solution may be preserved 
by using it in such excess that the chemical change has practically 
no effect, or by combining with it, as stated above, an acid which 
will not in itself be unduly irritating to raw surfaces. This end is 
accomplished by tartaric acid. In making up a solution, 1 part of 
bichloride and 5 parts of tartaric acid are added to as much water 
as is needed. Thus, in making up a solution of 1 : 1000 for surgical 
purposes, the following prescription may be employed. 

1$ — Hydrargyri chloridi corrosivi . . . . gr. xv (1.0). 

Acidi tartarici gr. xv vel 3J (4.0). 

Aquae destillatse Oij (960 mils.).— M. 

In the treatment of infected wounds bichloride solutions are used 
in the strengths of 1:500, 1:1000, 1:2000, and 1:4000. For the 



ANTISEPTICS 537 

irrigation of large cavities solutions of a strength greater than 1 : 10,000 
should rarely be employed; and even these dilute lotions have, when 
used in the peritoneal cavity, caused toxic symptoms. As tissues are 
devitalized by antiseptics the latter should not be applied to clean raw 
surfaces. Solutions of 1: 500 or 1: 1000 are used in cleansing the 
surface of the body. 

The ordinary method of preparing the surface of the body for oper- 
ation is as follows: The part is first thoroughly scrubbed with green 
soap and warm water, is shaved, and is again washed. It is then cleaned 
with alcohol 70 per cent., after which a scrubbing with bichloride 
solution of 1 : 1000 should follow. If no surgical interference is imme- 
diately indicated, the whole operative region should be enveloped in 
sterile gauze, and kept thus protected until the surgeon is prepared 
to operate. The moment the skin is incised normal saline solution 
should be used. The dressings, unless some peculiar form is used, 
may consist of sterile gauze, or of boiled, bleached, and sun-dried gauze, 
soaked in a 1 : 500 bichloride solution and subsequently washed and 
wrung out in a 1 : 4000 dilution of the same antiseptic. 

Iodine has become popular for skin disinfection. Not less than a 
4 per cent, solution of iodine in rectified spirit is employed. An 
immediate preliminary washing with soap and water is undesirable, 
since because of the swelling of the epithelial cells from this process 
the iodine does not deeply penetrate. Preliminary cleansing the night 
before is, however, not open to this objection. The operative area is 
painted with the iodine solution after anaesthesia is well started and 
again before operation. In patients with extremely delicate skins the 
iodine may be removed immediately after application by means 
of an alcohol compress or a 2 per cent solution of carbolic acid. The 
results from this disinfection are quite equal to those obtained by the 
more elaborate procedure described above. The iodine is simpler in 
its application, cheaper, and is open only to the objection that it occa- 
sionally irritates a delicate skin. This may be avoided, as a rule, by 
using freshly made preparations. As a direct application to infected 
wounds, tincture of iodine in full strength has given better results 
than has any other chemical. The requisite for complete cleansing is 
that the iodine must penetrate to every recess of the wound. Even a 
dirty, greasy skin can apparently be disinfected by one painting of the 
tincture. The addition of benzine seems to lessen its irritating qualities. 

Of waning popularity among the antiseptic preparations is phenol 
and its solutions. The particular value of this drug lies in the fact 
that its potency is equally developed in both albuminous and non- 
albuminous solutions. Like the mercury salts, its disadvantage 
lies in its toxic properties. It is usually used in solutions of 1: 20 
and 1: 40. The phenol of commerce is found in liquid form. In 
making solution for surgical purposes an ounce of this liquid is added 
of 20 or 40 ounces of water, according to the strength of the solution 
desired. Although phenol is soluble in 19.6 parts of water, solution 



538 REMEDIAL MEASURES OTHER THAN DRUGS 

does not take place immediately, and in making solutions of a 
strength of 1 : 20 either the water must be hot or a certain amount of 
time and considerable agitation of the mixture are required, other- 
wise globules of almost pure phenol are deposited in the bottom of the 
tray or vessel into which the solution is poured, and these, on coming 
in contact with the hands of the operator, exert an undesirable 
cauterant effect. 

The 1 : 20 solution at one time used for the disinfection of instru- 
ments and the cleansing of surfaces has now been abandoned except 
when other and better means cannot be obtained. If a phenol solu- 
tion is employed for irrigation or for cleansing compresses during an 
operation, it should not be stronger than 1 : 40. 

A property possessed by phenol, which renders it an unsafe medium 
for the impregnation of gauze, is its volatility. After exposure of a 
few hours to the atmosphere it wholly evaporates, leaving not an 
antiseptic but simply a sterile dressing. This fact is utilized by the 
surgeon in the preparation of the deeper layers of the dressing, which 
come in immediate contact with the edges of the wound. Since all 
antiseptics are more or less irritating to raw surfaces, healing will 
be promoted by a sterile rather than by an antiseptic application. 
By moistening in a phenol solution of 1: 20 a piece of boiled and 
sun-dried gauze sufficiently large to cover the wound-edges, the anti- 
septicity of this dressing is assured, and in a very few hours the heat 
of the body causes evaporation of all the phenol, leaving a sterile, 
non-irritating surface in contact with the wound. 

Even in proper solution, phenol greatly irritates the hands of 
the surgeon, and if used in a strength of more than 1:40 causes so 
much benumbing of tactile sensibility that manipulative skill is 
seriously interfered with. The cracked and fissured fingers resulting 
from the use of phenol lotions at times produce far more serious 
results than temporary pain and discomfort: many recesses are provided 
in the depths of which septic germs may successfully resist the action 
of antiseptic washes. Septic poisoning has been frequently due to 
this fact. Moreover, certain individuals exhibit an idiosyncrasy toward 
phenol, gangrene having resulted from a skin application of a strength 
not greater than 1 : 40. 

A 37 per cent, aqueous solution of formaldehyde gas is a power- 
ful disinfectant, but when used in efficient strength is both painful and 
irritating. In the strength of 1 : 2000, using normal saline solution as 
the diluent, it may take the place of bichloride lotion for flushing 
large cavities or cleansing extensive granulating surfaces. The vapor 
has its most useful application in disinfecting rooms, barracks, dress- 
ings, and instruments. (See Disinfection.) 

Iodoform occupies a unique place among antiseptics in having 
been almost universally accepted and used by surgeons and clinicians 
in spite of the fact that its germicidal action has been proved by 
laboratory research to be practically nil. It is found that nearly all 



ANTISEPTICS 539 

forms of pathogenic germs grow abundantly upon culture materials 
the greater part of which is made up of iodoform, and that injections 
of such germs, mingled with large quantities of iodoform, produce 
their characteristic effect upon living tissues with almost as great cer- 
tainty as though this drug had not been used; furthermore, it has 
been shown that iodoform is not even sterile, and that as employed 
by surgeons it is frequently a cause of infecting previously aseptic 
wounds; moreover, it is poisonous. In spite of this overwhelming 
evidence against it, the drug is still in favor. Recent researches 
have explained, in part at least, the reason for this contradiction 
between experimental and practical results. It has been well said 
that the human body is not a test-tube, and that bacteriological re- 
search cannot supplant the evidence of clinical observation. Elaborate 
investigation has shown that this drug acts as a powerful antiseptic, 
not by destroying germs, but by undergoing a decomposition in their 
presence, the products of which render the toxines, the result of 
germ-growth, inert. In this way suppuration is, to a certain extent, 
inhibited, or if present, its disastrous effects upon the system at large 
are prevented, since these are due to toxine absorption rather than 
to a direct effect of the micro-organisms themselves. It has been 
apparently proved that toxines, in themselves, and without the pres- 
ence of micro-organisms, can generate pus, but that where such 
toxines are mixed with iodoform before infection no pus is formed. 
If these septic chemical compounds are rendered inert, a powerful 
adjuvant to the destructive action of the germ upon living cells is 
removed, and thus the system is often enabled to overcome one enemy 
where two would have prevailed. The fact that iodoform is in itself 
not sterile is, from a practical standpoint, most important. Fortunately, 
sterilization is readily accomplished. A thorough washing in a 1 : 1000 
bichloride solution followed by a washing with freshly distilled water 
destroys all microorganisms. 

As employed in surgery, iodoform, after having been sterilized, is 
placed in small pill-boxes or wide-mouthed jars, over the opening of 
which is tied a single layer of antiseptic gauze; through this the iodo- 
form is sprinkled as desired over wound surfaces. It is rarely used 
except in the treatment of chancroids and of tuberculous lesions. 

Dakin's Fluid. — Recent military experience has shown that Dakin's 
fluid is possessed of high antiseptic value hence it has been extensively 
used for irrigation and the wet dressing of infected wounds. 

Long before we knew anything of micro-organisms as factors in disease 
medical men knew that "Labarraque's solution," known officially as 
Liquor Sodce Chlorinate, arrested suppuration and was efficient in 
cleansing fetid sores. It did good because of its chlorine content. 
Instead of using chlorinated soda we generally employ chlorinated 
lime. This possesses, however, irritant properties because of its 
marked alkalinity, and as the chlorinated lime from which it is 
made is of varying strength as it is found on the market, the effects of 
the chlorine content were very variable. It is interesting to note how 



540 REMEDIAL MEASURES OTHER THAN DRUGS. 

we at times miss a fact near at hand and after trying many routes or 
methods, arrive near our starting-point to find it is the best place after 
all if some slight but important modification is made. The prime con- 
siderations in an antiseptic are that it shall be unfavorable to germs, 
not harmful to the cells of the body'and that it shall not be expensive 
nor difficult to prepare and keep in an effective form. Furthermore , 
its consistency should not be such as to block drainage nor should it 
require very frequent changing. 

There is practically no substance known which meets these condi- 
tions, but Daufresne's modification of Dakin's solution, if prepared 
with proper precautions, without doubt far surpasses antiseptics which 
have been generally employed during the time that old-fashioned 
dilute Labarraque's solution was shelved. 

Dakin's original solution failed because of its irritating properties 
and uncertain results. It was made by dissolving 140 grams of dried 
sodium carbonate in 10 litres of water and adding 200 grams of chlorin- 
ated lime. This mixture is repeatedly shaken during a period of one* 
hour when the supernatant fluid is siphoned off and filtered. As this 
fluid is excessively alkaline 40 grams of boric acid was added. 

Dakin's solution, as just stated, has a varying alkalinity and an uncer- 
tain content of chlorine. Daufresne has devised the following plan 
whereby these faults are set aside : Place 184 grams of chlorinated lime 
containing not less than 25 per cent, chlorine in a bottle, or flask, holding 
12 litres and add 5 litres of water. Shake repeatedly during six hours. 
When preparing this solution make a second one by dissolving 92 grams 
of dried sodium carbonate and 76 grams of sodium bicarbonate in 5 litres 
of water. After the six-hour period referred to is ended add the sodium 
carbonate solution to solution No. 1. Shake the mixture well and then 
allow at least half an hour to elapse for full reaction to occur. Now 
siphon off the supernatant fluid and filter, when it is ready for use if the 
ingredients and technique have been perfect, but it must be kept tightly 
corked in a dark vessel and should not be used after the lapse of seven 
days. To determine that the solution is not too alkaline, and therefore 
irritating, add to 20 mils, of it 0.2 of phenolphthalein when, if the fluid 
is proper for use, there will be no red color. To determine if the chlori- 
nated lime which is used is up to at least 25 per cent, strength, mix 20 
grams of it with great care in 1 litre of water. Shake it occasionally 
during a period of several hours and filter. Pipette 10 mils, of the 
clear filtrate and add thereto 20 mils, of a 1 to 10 solution of potas- 
sium iodide and 2 mils, of acetic or hydrochloric acid. Into this 
solution add drop by drop a decinormal solution of sodium thiosulphate 
until the tested fluid is colorless. If the mils, of thiosulphate solution 
required to decolorize is multiplied by 1.775 the weight of available 
chlorine existant in 100 grams of the chlorinated lime is determined. 
If the chlorine content varies from 25 per cent, named above then the 
quantities of the various ingredients must be altered, and Daufresne 
has given these variations in the following table: 







ANTISEPTICS. 






ENTITIES OF 


INGREDIENTS 


FOR TEN 


LITRES OF 


DARIN'S SOLUT1 


Titer of 


Chlorinated 


lime, 


Anhydrous sodium 


Sodium bicarbonate 


chlorinated lime. 


gm. 




carbonate, 


gm. 


gm. 


20 


230 






115 




96 


21 


220 






110 




92 


22 


210 






105 




88 


23 


200 






100 




84 


24 


192 






96 




80 


25 


184 






92 




76 


26 


177 






89 




72 


27 


170 






85 




70 


28 


164 






82 




68 


29 


159 






80 




66 


30 


154 






77 




64 


31 


148 






74 




62 


32 


144 






72 




60 


33 


140 






70 




59 


34 


135 






68 




57 


35 


132 






66 




55 


36 


128 






64 




53 


37 


124 






62 




52 



511 



There are several essential points in regard to the use of this solu- 
tion if it is to produce adequate results. Commercial hypochlorites 
are usually inconstant and therefore each sample should be analyzed 
before it is used. The solution must be protected from light and 
heat. It must reach every part of the wound and infected spaces must 
be opened up so that this is accomplished. When every part is found 
to be sterile by cultures the wound may be closed and promptly heals. 
Through and through drainage does not do well as pockets escape 
irrigation. Irrigation is accomplished by multiple perforated tubes 
each placed in a pocket. (Fig. 66.) 

Because of the obvious difficulties in the preparation and keeping of 
Dakin's solution toluene sulphondichloramine, in other words, toluene 
dichloramine, or " dichloramine-T, " has been introduced as a substitute, 
depending for its very high germicidal action upon the large amount of 
active chlorine which it contains. Dichloramine-T appears as a yellowish 
white crystalline substance, when made with chloroform, possessing 
rather a sweet odor with some pungency resembling chlorine. When 
made commercially on a large scale in vacuum it appears as a powder. 
It is used in a strength varying from 2 to 5 per cent. , the solution having 
been made by dissolving it in a mixture of eucalyptol and paraffine oil. 
The use of this mixture was resorted to first because dichloramine-T 
is practically insoluble in water and the use of eucalyptol causes the 
chlorine to be given off slowly over many hours instead of all at once. 
Thus, while most of the chlorine may be lost from Dakin's solution in 
a few minutes, the oily dichloramine-T solution lasts as many hours. 
The oil further acts as a protective dressing in itself and permeates all 
parts of the wound so that very small quantities cover a very large 
area. Any irritation of the skin can be avoided by using light dressings. 

Even when eucalyptol is employed the product, as already stated, 
soon becomes of uncertain strength. Dakin has improved upon 



542 



REMEDIAL MEASURES OTHER THAN DRUGS. 



the eucalyptol-paraffine mixture by treating any pure paraffine wax 
that melts at 50° C. or over, with chlorine gas, at a temperature of 
from 120° to 140° C. until an increase in the weight of the paraffine 
amounts to 45 to 55 per cent. Hydrochloric acid develops which 
is removed by shaking with about 5 per cent, of dry sodium car- 
bonate and the hot oil is then filtered through dry fluted paper. 
It is now ready as a solvent of the dichloramine-T and is called " Chlor- 
cosane" because the predominating hydrocarbons of solid paraffine 
are designated by terms ending in "cosane," the prefix "chlor" 
indicating the presence of chlorine. When making the solution of 

Fig. 66. 




Apparatus for applying Carrel-Dakin solution. This apparatus is furnished 
by instrument dealers. A, reservoir gradual ed; B, clamp for regulating flow; C, 
sight feed cup; D, four-way glass distributor; E, perforated distributing tubes with 
ends tied. When used for surface ends are covered with Turkish toweling; F, five- 
way glass distributor; G, one tube glass distributor; H, two-way glass distributor; /, 
syringe for applying solution by hand; «/", flask for use with syringe. 



dichloramine-T in chlorcosane it is best to warm one-fourth of the 
latter to 80° C, then add the dichloramine-T, usually not in excess of 
5 per cent.; and stir until it is dissolved, when the remainder of the 
chlorcosane at room temperature is added and filtered. When 
decomposition of the dichloramine-T in chlorcosane has occurred it 
shows an abundant deposit and the oil should be discarded. If soon 
after it is made it is found to be cloudy or precipitated from exposure 
to cold it may be gently warmed when, if not decomposed, it becomes 
clear. 

Dichloramine-T is without doubt, up to date, the best wound dressing 



ANTISEPTICS. 543 

that we have, both as to cost and efficiency, particularly where large 
numbers of wounded are to be treated and it is so frequently made that 
there is always a supply of the fresh preparation on hand. As, however, 
it soon deteriorates when kept it does not lend itself as an antiseptic 
dressing to the private practitioner who only has an opportunity to 
employ it at long intervals. Sunlight, water and alcohol decompose 
chloramine, which must be kept in a dark amber glass bottle. Blue 
glass containers are not efficient because the rays of light which pass 
through it decompose the compound. So essential is it that no water 
shall come in contact that a glass pipette which has been sterilized 
by boiling and is still wet must not be introduced into the solution, 
because the minute amount of water adhering to the pipette will result 
in decomposition. A dry pipette is the best way to apply it. A very 
minute amount of the oily solution is required and it is a mistake to 
use it too freely. Dichloramine-T will fail as an antiseptic dressing 
if dirt, foreign bodies and pieces of bone are left in the wound. Use 
only a light dressing. 

Superficial wounds of large extent and burns may be treated by 
dichloramine-T according to the plan of Lee and Furness. They 
spray the area with a 1 to 2 per cent, solution in chlorcosane. Over 
this they place strips of paraffinized mosquito netting made in the 
following manner. Ordinary y^-inch netting is not washed to get rid 
of the sizing but sterilized by heat as are ordinary dressings. Pick 
up the strips of netting with forceps and dip in thoroughly melted 
paraffine wax which melts at about 50° C. Then lift them out of the 
wax and hold them, or hang them, over the heat so that the excess of 
melted wax runs off leaving the interstices open. Then cool and keep 
for use by wrapping in sterile towels. The method permits free drainage 
of secretion which the ordinary paraffine method (see Burns, Part IV) 
of treating burns lacks and obtains the primary antiseptic properties 
of the dichloramine-T. 

Kreolin is a preparation obtained from English coal by dry distil- 
lation, and because of its feeble toxic action is often preferred to phenol. 

The extravagant claims advanced for kreolin in regard to its germi- 
cidal power have not been confirmed by bacteriological investiga- 
tion. In solutions containing albumin it is not efficient as a germicide 
in strengths of less than 1 : 100, its power being somewhat less than 
that of phenol. 

Kreolin, though insoluble in water, readily forms an emulsion quite 
as efficacious in its antiseptic properties as a true solution. Since this 
emulsion is opaque, it is scarcely applicable for immersing and steril- 
izing instruments, the latter not being readily found. It is admirably 
suited, however, for cleansing the hands, a 5 per cent, solution neither 
cracking the skin nor benumbing the sensory nerves. In irrigating 
large wounds, cavities of the body, and particularly as a means of 
preventing sepsis or aborting it in gynecological work, kreolin can be 
warmly commended. It may be employed in a strength of from 0.2 
to 5 per cent. 



544 REMEDIAL MEASURES OTHER THAN DRUGS. 

Among the many antiseptic agents of less importance may be men- 
tioned Peroxide of Hydrogen. This drug comes in what is termed a 
ten-volume solution. By this it is meant that ten volumes of feebly 
combined oxygen are contained in each volume of the liquid. It is 
applicable, not to sterile surfaces, but to suppurating wounds and 
sinuses. It is used in the strength of from 50 per cent, up to full 
concentration. When this drug is poured into a suppurating sinus or 
cavity an ebullition takes place, which ceases only when the drug is 
exhausted or the dead material has been oxidized. It should never 
be used in a cavity from which the gas cannot readily escape. 

Chloride of Zinc has been extensively employed in some clinics as 
an antiseptic application. It is used in 10 per cent, solutions, and is 
applied when the field of operation is probably infected by pre-existing 
pus-formation. Although bacteriological research has shown that 
this agent possesses feeble antiseptic power, clinical experience demon- 
strates its value when applied to infected surfaces. Lately the Zinc 
Phenolsulphonate has to a great extent replaced the chloride, as it is 
less toxic and irritating and far more potent. 

For the sterilization of mucous surfaces a saturated aqueous solu- 
tion of Boric Acid is commonly employed. More potent than this 
are the silver salts, silvol protargol, and silver nitrate in solutions 
of 1: 2000 to 1: 1000. (See articles in Part II.) 

An omission of the details of cleansing the hands of the surgeon 
and assistants in preparing for an antiseptic operation is scarcely 
permissible when writing upon the subject of antisepsis. The most 
approved method is as follows: 

The hands and forearms are thoroughly brushed in hot soap-suds 
for three minutes, after which the nails are carefully cleaned by 
wooden toothpicks and a brush, and the washing repeated; the hands 
are then washed in alcohol for one minute, special attention being 
paid to the nails; finally they are soaked for one minute in a solution 
of bichloride (1:1000), and during the course of the operation, if 
rubber gloves are not used, are occasionally washed in a solution of 
one-half this strength. If it is necessary to lift a chair, to turn the 
patient, or to touch any object which has not been previously steril- 
ized, the hands should be enveloped in towels wrung out in 1 : 1000 
solution or immediately washed again. Another method which has 
been found by Kelly to be the best, bacteriologically and practically, is 
to cleanse the hands and nails by scrubbing with hot water and soap, 
and then immerse the hands and arms in a saturated solution of 
permanganate of potassium made with hot water. After this the skin 
is decolorized by immersion in a saturated solution of oxalic acid. 
Finally, the oxalic acid is washed off with hot sterilized water. 

Any method which irritates or cracks the skin of the hand is dan- 
gerous. The only certain way of avoiding infection from the hands 
of the operator lies in the use of rubber gloves. 



ANTITOXIN. 
ANTITOXIN. 



545 



The method by which protection is obtained by the use of antitoxic- 
serum is best explained by the hypothesis of Ehrlich, which has with- 
stood the test of scientific investigation very well and is now generally 
admitted to be the true explanation of this interesting subject. It is 
assumed that all cells have the power of combining with the food- 
products that are needed by them for sustenance by means of receptors 
or parts which have an affinity for each form of food required. A 
cell may have many of these receptors, each of which is suited to 
the appropriation of a definite kind of food-stuff, and is unable to 
appropriate or become attached to any other variety of food. As soon 
as a receptor has been utilized for the appropriation or attaching of 
a particle of food, the cell immediately makes another receptor, and, in 
many instances, makes a far greater number of these receptors than 
is necessary, particularly if the demand is very great. These extra 
receptors are, when made in excess, thrown off into the blood, where 
they exist unattached to the cells which originated them (Fig. 67). 

The poisons or toxins of disease are known to be complex proteid 
bodies closely resembling food bodies, and therefore these poisonous 
products of bacteria unite with the receptors of a cell, and instead 
of nourishing it, produce its death. An animal or a man may be natu- 
rally immune to a disease by reason of the fact that the cells in his 
body may be devoid of recep- 



Fig. 67. 



tors capable of combining with 
a given poison, or by reason of 
the fact, which is the case in ac- 
quired immunity, that his cells 
have thrown off so many extra 
receptors into the blood that the 
toxins unite with them, and as 
they are unattached to cells the 
animal is not affected. These 
receptors are also called anti- 
bodies, and when serum of a 
horse is injected into the tissues 
of a child suffering from diph- 
theria, this serum contains so 
many antibodies or receptors 
that the toxins of the disease 
are locked in the embrace of 
the antibodies in such large num- 
bers that the cells of the body 

itself are not overwhelmed by the infection. In the case of diseases 
such as scarlet fever and smallpox, which rarely attack the same person 
twice, it perhaps may be said that immunity is conferred by the tis- 
sues being trained or educated, as it were, to prepare antibodies in 
such large amounts when called upon that the entering wedge of a 
new attack is snapped off at the moment it begins to enter the field. 
35 




Showing separation of receptors or antitoxins, and 
combination of toxins with free antitoxins. 



546 REMEDIAL MEASURES OTHER THAN DRUGS. 

That an actual combination takes place seems to be proved by the 
experiments of Martin and Cheny, who found that the toxin of diph- 
theria will pass through a Berkefeld filter covered with gelatine, whereas 
the antitoxin will not do so because its molecule is too large. If the 
toxin and antitoxin are mixed, the toxin ceases to pass through the 
prepared filter because, having united with the receptor, its molecule 
is too large. 

The horse, being naturally able to resist diphtheria-infection to 
the extent of complete immunity, it becomes necessary, in order to 
make the resistance of his blood-serum absolute, to stimulate, if we 
may use such a term, his antitoxin-preparing powers, and with this 
object in view injections of the toxin derived from cultures of diph- 
theria germs are made into the blood of the naturally immune brute. 
As a result, the serum of the blood of the animal possesses the power 
of not only resisting diphtheria poison while in its own vessels, but 
also confers immunity of a temporary kind upon any other animal 
into whose body some of it is injected. It having been found experi- 
mentally that antitoxic horse serum when injected into the susceptible 
guinea-pig renders that animal to a great extent insusceptible to inocu- 
lation by diphtheria, it was but a step to the use of the same agent 
for the protection of a child. 

Besredka, and others, have seemed to prove that the danger of 
severe serum sickness or anaphylaxis can be foretold, and in many 
cases prevented by the preliminary injection of 1 or 2 mils, of antitoxic 
serum, following this testing dose by the full quantity some minutes 
later. (For Anaphylaxis see article on Diphtheria in Part IV.) 

A number of antitoxic sera are now employed, although none of 
them give results equal to those produced by antidiphtheritic serum. 

Anti diphtheritic Serum. 

Serum Antidiphthericum Purificatum, U. S. — While all of the anti- 
toxins seem theoretically to promise well, in practice we find that only 
one is absolutely reliable, and it has received general recognition. 
This one is the antitoxin of diphtheria. The following process is 
followed in its preparation : a pure culture of the bacillus of this disease 
having been grown, colonies of the bacillus are picked up off the 
culture gelatin and placed in tubes of blood-serum, which in turn 
are placed in an incubator. After a time flasks of bouillon are inocu- 
lated by the germs. These flasks are then placed in an incubator, 
where there is rapidly produced the diphtheritic poison in the bouillon. 
After a length of time sufficient for the development of the poison 
the fluid has added to it a small amount of some preservative, and is 
then filtered through unglazed porcelain, whereby all the bacilli and 
other particles are separated, the filtrate being a clear, straw-colored 
fluid. This is the fluid containing the toxin. The toxin of each 



ANTITOXIN. 547 

flask varies in its power, so it is necessary to determine its activity. 
This is done by injecting it into guinea-pigs, which animals are very 
susceptible. Usually from 2 to 100 milligrammes are required to 
cause death within a few days. A young, healthy horse now receives 
about 1.0 mil. of the toxin by subcutaneous injection; that is, ten 
times the fatal dose for the guinea-pig, provided the fatal dose was 0.1. 
Horses are chosen because they are naturally immune, have large 
amounts of blood-serum, and are easily handled. Gradually increas- 
ing doses are given until the horse can readily receive several hundred 
times the first dose without any ill-effects. The horse is now capable 
of rendering antitoxic serum, and he is bled. The blood-serum is 
separated and purified and is then tested to determine its power. 
The tests applied are such that the strength of serum is measured by 
units of antidiphtheritic serum. 

An antitoxin unit is the unit established by the United States Public 
Health and Marine Hospital Service. It can be defined approximately 
by the following description of the process used: Ten times the 
smallest fatal dose of toxin is injected into a guinea-pig, and at the 
same time 0.1 mil. of the horse serum is injected. If the guinea-pig 
survives, the serum is said to contain 1 unit of antitoxic power in 
each milliliter, and as the dose given was only one-tenth of a milliliter it 
follows that each milliliter is 10 times the amount of serum sufficient 
to protect a guinea-pig from 10 times a fatal dose of toxin. If this 
strength of serum were used, very large doses would have to be given 
to get any effect in man ; so we are not satisfied with this result, and 
by continued dosing of the horse we may obtain, from his blood, 
serum which will be active in protecting the guinea-pig, not in the 
dose of 0.1 mil., but in the dose of 0.001 mil. Such a serum con- 
tains, therefore, 100 antitoxin units to the milliliter. A dose of 
5 mils, of this strength would, therefore, give 500 antitoxin units. 
Even this is not satisfactory. Accordingly, most of the serum on 
the market is so strong as to contain 500 or even 1750 antitoxin 
units in each milliliter, so that 2 mils, of the latter would be a dose 
of 3500 units. These very high-potency serums diminish in efficacy 
if kept for any length of time, but unless decomposed are to be 
employed when fresh antitoxin is not at hand, as they remain potent 
for many months. All serum of whatever strength should be obtained 
as fresh as possible. 

It has been found that the antitoxic substance is in the globulins 
of the serum or at least closely associated with them, and, therefore, 
there is now on the market liquid and dry Antidiphtheritic Globulin 
(Serum Antidiyhthericum Siccum, U. S.), which is equally efficacious 
with ordinary antidiphtheritic serum, and can be given in about one- 
half the dose as to bulk. The dry form is dissolved in normal salt 
solution before injection. (See Diphtheria, Part IV.) 

A dose of antitoxin given after the lapse of ten days following a 
previous dose may rarely develop grave symptoms. (See Diphtheria.) 



548 REMEDIAL MEASURES OTHER THAN DRUGS. 

Antidysenteric Serum. 

This serum is used only in bacillary dysentery, and is of no value 
in amoebic dysentery, being prepared from the Shiga-Flexner bacillus. 
It is not of great antitoxic power and must be given in large doses. 
The best results follow the intravenous injection of from 30 to 
80 mils, once or twice daily. This should be followed by about 
300 mils, of normal saline solution. Graham, of the British Army, 
states that in very toxic cases a 5 per cent, solution of glucose is 
preferable to normal saline solution. If not given intravenously 
the serum must be used intramuscularly because its subcutaneous 
absorption seems too slow. The chief immediate benefit seems to be 
a decrease of abdominal pain and in the number of stools. As such 
large doses are prone to produce serum sickness or even anaphylaxis in 
sensitive persons, as in asthmatics, this may be avoided by the Besredka 
method of giving 1 or 2 mils, followed in five or ten minutes by 5 mils, 
and, after an equal interval, the rest of the dose is injected very slowly. 

Antigonococcic Serum. 

Antigonococcic serum, prepared from the blood of horses, is now 
recognized as a valuable remedy in the treatment of gonorrheal rheu- 
matism. It has not, for unknown reasons, proved of material value 
in the treatment of gonorrheal urethritis or epididymitis. The method 
of using it consists in injecting 2 to 12 mils, of the serum intramuscu- 
larly, or hypodermically, at intervals varying from two to six days. 
The best site for the injection is the abdominal wall. It causes both 
a local and a general reaction in a few cases. The local reaction 
consists in dermatitis or urticaria and enlargement of the inguinal 
glands. The general reaction consists of a rise of temperature of from 
one to two degrees and a quickening of the pulse. All these symptoms 
disappear in about twenty-four to forty-eight hours. Doses of this 
serum given at long intervals rarely cause anaphylaxis, as does 
any foreign protein substance. (See Diphtheria.) 



Antimeningitis Serum. 

Flexner has produced an antimeningitis serum from horses, inocu- 
lated with the diplococcus intracellularis and its products, which has 
proved itself capable of reducing the mortality of epidemic cerebro- 
spinal meningitis about 60 per cent, if it is used early enough to protect 
the patient from well-developed lesions. The serum not only saves 
life, but greatly decreases the frequency with which those patients who 
recover from the attack suffer from sequelse, such as deafness, blind- 
ness, and deformities. It causes the turbid cerebrospinal fluid to 
become clear, and seems to facilitate phagocytosis and to arrest the 
growth of the specific micro-organism as well. Its effects are bacteri- 



ANTITOXIN. 549 

cidal rather than truly antitoxic. The dose should be repeated daily 
to prevent relapses and to produce a cure. Antimeningococcic serum 
is not given hypodermically or intravenously but by intraspinal injec- 
tion. (See Lumbar Puncture.) Before it is injected an amount of 
cerebrospinal fluid equal to the amount of serum to be injected should 
be allowed to flow out of the needle. Although the fluid withdrawn 
should be examined microscopically and cytologically, to make the 
diagnosis certain, the serum should be immediately injected, as delay 
may be fatal, and even if the symptoms be due to the pneumococcus or 
the tubercle bacillus no harm will be done. While the puncture is 
being made and the fluid withdrawn the blood-pressure should be 
taken. If the fall of blood-pressure equals 5 to 10 mm. the withdrawal 
should cease. So, too, when the serum is being introduced, if the press- 
ure falls care should be exercised to be more gentle, and if the pressure 
falls as much as 15 or 20 mm. the injection had better be stopped. 
Sharp and marked blood-pressure variations can usually be avoided, 
if the fluid is not allowed to escape too fast and the injection is not 
made too forcibly and rapidly. The dose of the serum is measured not 
by units, but by cubic centimetres. The first dose of antimeningitic 
serum varies from 5 to 20 mils, for a child to 20 to 50 mils, for an 
adult. Infants under one year of age should rarely be given more 
than 10 mils. The maximum doses for other ages may be considered 
as follows: One to five years, 15 mils.; five to ten years, 20 mils.; ten 
to fifteen years, 25 mils. ; fifteen to twenty years, 30 mils. ; adults, 50 
mils. 

The injection of antimeningococcic serum may induce an aseptic 
meningeal irritation (meningismus) with fever and rigidity of the 
neck. If this is the case the injections should be stopped. If these 
symptoms are due to a relapse of the disease it should be continued. 
The question is settled by examining the spinal fluid which in men- 
ingismus contains its normal glucose and does not show meningococci. 
If glucose is absent serum should be used. Turbidity is of little value 
as an aid in diagnosis under these conditions. 

Antipneumococcic Serum. 

It is now a recognized fact that the pneumococcus occurs in three 
definite and distinct types, and a number of irregular or inconstant 
types form a class called Type IV. The mortality varies greatly 
with the type, Type III being the most lethal, the death-rate being 
as high as 50 per cent. Fortunately this type is not a common one. 
Type I and II have a death-rate of about 25 per cent, and Type IV 
about 12 per cent. Up to the present time it has not been found 
possible to produce serum antitoxic to any type except Type I, and 
even this is still sub judice. For the accurate use of the serum for 
Type I a competent bacteriological examination to determine the 
presence of this particular coccus is essential and this, in many cases 



550 REMEDIAL MEASURES OTHER THAN DRUGS. 

is impossible, as the delay in obtaining it is fatal. The serum if used 
must be given intravenously in a dose of from 50 to 100 mils, three or 
four times a day until marked improvement is manifest. The infection 
usually causes a sharp fall in temperature followed in some hours by 
a rise which calls for another dose. In Type I infection it is claimed 
that Type I serum reduces the mortality from 25 to 10 per cent. 
Before the intravenous injection is given a few drops of the serum may 
be injected intradermally to determine if there is danger of anaphylaxis. 
If in about an hour a definite hyperemic area develops at the point of 
injection anaphylaxis is probable and if used at all the doses should 
be small and at first given hypodermically. 

Antitetanic Serum. 

Antitoxin fails in many cases of tetanus because the tetanus toxin 
unites so rapidly with the cells in the spinal cord and brain that by the 
time the symptoms are present and the antitoxin is given the damage 
is past repair, and the antitoxic bodies cannot combine with the toxic 
bodies because they are already combined with the cells of the tissues. 
If tetanus antitoxin is given at the time the wound is received, it is as 
efficacious as is antidiphtheric serum in diphtheria. (See Tetanus.) 
The point is to give it early and in large amounts. If any early symp- 
toms are present, 25,000 to 50,000 units should be used at once; thus, 
1500 units into and around the nerve running to the infected area, 
10,000 units intraspinally, and 25,000 or 30,000 units intravenously. 

These injections should be repeated every twelve or eighteen hours 
until improvement is marked. A blazing fire must be overwhelmed 
at once if life is to be saved. 

The minimum dose as a preventive is 3000 units. In urgent cases 
three or four times this amount should be used, injected intraspinally 
and into the nerve trunk leading from the part primarily infected, and 
it should also be given in warm salt solution intravenously in the dose 
of 20,000 to 30,000 units. 

The definition of a unit of antitetanic serum is as follows: "An 
antitetanic unit is ten times the amount of antitetanic serum that 
will neutralize the L+ dose of tetanus toxin when the two are mixed 
together and injected into a test guinea-pig weighing 300 to 350 grams." 
The L+ dose is approximately 100 times the minimum fatal dose. 
(L+ stands for lethal dose +.) It should be remembered that the 
neutralizing power of antitetanic serum is approximately ten times 
as great as that of antidiphtheric serum, unit for unit. 

The U. S. Department of Public Health and Marine Hospital Service 
has decided that after April 1st, 1907, antitetanic serum packages must 
bear the following statement: "This package contains 1500 antite- 
tanic units, according to the U. S. Government standard, approved 
April 1st, 1907." It is official as Serum Antitetanicum, U. S., Serum 
Antitetanicum Purificatum, and Siccum, U. S. 



ANTITOXIN. 551 

Antistreptococcus Serum. 

As is well known, infection by the streptococcus produces the more 
severe forms of septicaemia such as are met with in the puerperium, 
after injuries and operations, in erysipelas, and in association with 
such specific infectious processes as scarlet fever and diphtheria. In the 
latter diseases under these circumstances there is probably a double 
infection. While the theoretical basis upon which the use of this serum 
rests is good, the results from its use have not been so valuable, prob- 
ably because in many instances the infectious process has not been 
solely due to this micro-organism and in the other disease organisms 
produce their effects uninfluenced by the serum used. The best results 
have been obtained from its use in puerperal and post-traumatic sepsis, 
but only in the presence of well-marked and positive streptococcic 
infection would the writer resort to it. Its method of employment is 
identical with that of diphtheria antitoxin. Care should be taken to 
obtain the serum from a reliable manufacturer. It would seem prob- 
able that in some cases of ulcerative endocarditis this serum is the best 
treatment that can be used. The dose of this serum is usually 10 to 
20 mils, every twelve hours, according to the age of the patient and 
the severity of the infection. Doses of 50 to 150 mils, have been given 
intravenously in severe cases. 

A very careless custom has arisen among some members of the pro- 
fession in that they call any biological or bacteriological product used by 
hypodermic injection a "serum," thereby confusing in their own minds 
and the minds of the laity antitoxins, vaccines, phylacogens, protein 
bodies of various types, and even glandular extracts. This carelessness 
is not only to be condemned because it is an error in itself but also 
because, as all these products depend for their activities upon the 
different effects which they produce in the body, the erroneous use of 
the word "serum" leads to an indefinite conception of how each pro- 
duct acts and leads not only to empiricism but to failure to get good 
results. A serum contains an antidote to a poison, a vaccine (see 
Vaccines) stimulates the body to resist the specific germ present, and 
a glandular extract supplies the body with something which its own 
glands fail to produce in sufficient quantity for normal function. 
There is only one serum, properly so called because it is actually horse 
serum, which acts in a manner resembling that of a vaccine and that is 
antimeningococcic serum which as already stated is not an antitoxin 
but causes the cells in the spinal fluid, when it is given, intraspinally 
to devour more of the meningococci, in other words, it increases the 
phagocytic power of the cells. 



552 



REMEDIAL MEASURES OTHER THAN DRUGS. 



BIER'S HYPEKffiMIC TREATMENT. 

Bier's hypersemic treatment depends upon the fact that when nature 
attempts to combat an inflammatory or infectious process she usually 

Fig. 68. 




Sh^ws elastic bandage in place around the arm, its ends tied with tapes. If the bandage 
is to remain on for a number of hours, it is advisable to apply a strip of adhesive plaster, to 
guard against the tapes becoming undone. Note the engorgement of the subcutaneous veins 
of the forearm, showing the effect it is desired to produce by the bandage. (Meyer and Schmie- 
den,) 

produces an active hypersemia in and about the part involved. In 
other words, by the use of a given piece of apparatus an attempt is made 
to aid nature combat pyogenic infections by an added hypersemia. 
In applying this method, care must be taken not to interfere with 
the free circulation of blood. The circulation may be slowed, but 
not blocked, and if the apparatus applied cuts off the pulse in the 
distal part of the limb, it is capable of doing great harm. The method 
of producing congestion is by the use of bandages or various forms of 
vacuum apparatus. Thus, in the arm or the leg, an ordinary Esmarch 
bandage may be employed (Figs. 68, 69, 70, 71, 72, 73). About 



Fig. 69. 




Technique employed for the production of obstructive hyperemia at the shoulder-joint. The 
folded piece of cloth is placed loosely around the neck. A piece of stout rubber tubing, under 
the required tension, is fastened on top of the shoulder. Two pieces of bandage are attached 
to the rubber tubing in front and behind and tied in the axilla of the healthy side, pulling the 
ring thus formed well over toward the median line. (.Meyer and Schmieden.) 

Fig. 70. 




Suction apparatus for the elbow-joint. The illustration shows how the elbow, which when 
introduced was entirely extended, has been bent slightly by the suction process in consequence 
of the edema and hyperemia produced. The accompanying pain is very slight. (Meyer and 
Schmieden.) 

(553) 



554 



REMEDIAL MEASURES OTHER THAN DRUGS. 

Fig. 71. 




Illustrates the application of Klapp's suction cup in a patient afflicted with a carbuncle of the 
neck. (Meyer aifd Schmieden.) 

Fig. 72. 




Shows the application of the large suction glass to the breast. Negative pressure is produced 
by the suction-pump. (Meyer and Schmieden.) 

the shoulder a piece of rubber tubing held in place by a bandage 
around the neck may be used; about the upper scrotum a piece of 



CARBON DIOXIDE SNOW. 

Fig. 73. 



555 




Showing the Bier apparatus for production of mobility in stiffened tendons and joints. (Kan- 

avel.) 

similar tubing tied or held together at the ends by a clamp may be 
applied. 

; CARBON DIOXIDE SNOW. 

Carbon dioxide snow is usually obtained from large steel cylinders 
of liquid carbon dioxide, these cylinders being obtained from manu- 
facturers of soda-water supplies. Another source is the smaller cylin- 
der of liquid carbon dioxide sold by automobile-supply houses for the 
easy inflation of tires. One of these small cylinders usually provides 
enough snow for one treatment or for several treatments if the patients 
are seen one after another. The escape of the carbon dioxide, whereby 
the so-called snow is formed, is controlled by a small valve cock. This 
snow has a temperature of about 85° F. below zero. The object of 
employing this snow is to obtain the effects of extreme cold upon 
localized areas which need treatment. A very satisfactory manner of 
molding the snow so that it is easily applied is to tie or hold a piece of 
thick chamois skin over the nozzle of the cock in such a way that a small 
pouch or pocket is formed, and the tank is then tipped slightly so as to 
bring the liquid which the tank contains in direct contact with the cock. 



556 REMEDIAL MEASURES OTHER THAN DRUGS. 

The snow collects in the chamois pocket and while in the chamois is 
molded by the fingers in any shape desired, or, holding it in the chamois 
skin, it can be cut or pared or shaped by ramming it in a hard rubber 
mold, such as an ear or nose speculum. The operator's fingers are 
protected from the intense cold by means of the chamois skin, and one 
end of the mold of snow is then placed against the diseased area and 
held there from ten to thirty seconds, or longer if the disease is deep- 
seated. When used from ten to thirty seconds it acts as a stimulant. 
When a destructive or cauterant action is desired it is applied from 
thirty seconds to a minute. On removing the pencil, the area to which 
it has been applied is seen to be depressed, and frozen white and hard. 
Around this frozen area is a slight, narrow, zone of erythema. Thaw- 
ing takes place in a minute or two, the part becoming red and sometimes 
slightly swollen. Later on, small vesicles or blebs form, which, if need 
be, can be punctured. Several days later slight exfoliation, or thin 
crusting, takes place. After a time the scab drops off, leaving a very 
slight scar or, perhaps only a mere white mark, the permanent lesion 
depending, of course, upon the severity of the action. Large areas 
should not be exposed at the same time, but small spots should be 
selected for each treatment. 

Therapeutically, carbon monoxide snow is used by dermatologists 
in treating lupus erythematosus, and in varied types of angioma, par- 
ticularly in those cases which present small circumscribed elevated 
spots, as in early infancy. It does less well in the so-called port wine 
marks. It is also sometimes employed to remove the brownish or 
dark spots forming on the hands and face of elderly people, and in 
certain cases of superficial epithelioma. It has also been employed in 
xanthoma. 

CLIMATIC TREATMENT. 

(See Springs and Climates.) 

COAGULOSE. 

Coagulose is an anhydrous product obtained by precipitating normal 
horse serum and contains a hemostatic ferment. It is used to control 
persistent hemorrhage from small vessels which cannot be occluded 
by ligation or compresses, as after operation in certain cases and in 
the hemorrhage of the newborn, and in hemophilia. It may also be 
used to control the various forms of internal hemorrhage. 

Into the sterile glass bulb in which the powder is marketed is placed 
6 to 8 mils, of sterile water at body heat. The bulb is then closed 
and shaken until solution occurs. The fluid is then drawn up into a 
sterile syringe and given hypodermically. The amount of powder is 
the equivalent of 10 mils, of fresh serum, and the dose may be repeated 
if need be in two or three hours. The dose for hemorrhage in the 
newborn is as large as that for adults. 

Powdered coagulose may also be sprinkled over bleeding surfaces or 
placed in position on a tampon. 



COLD AS A REMEDY. 557 

COLD AS A REMEDY. 

Cold, or the rapid abstraction of heat, is a remedial measure that 
is nearly always available, and is possessed of very great power for 
good in properly selected cases. We may divide its use into its local 
application, for a superficial, limited, deep-seated, or distant influence, 
and its general application for the purpose of affecting the entire body. 

When cold is applied for its limited and local action, it is always 
used with two objects in view — namely, to cause localized contraction 
of bloodvessels which through inflammation are engorged so that the 
parts are reddened and swollen, or temporarily to anaesthetize or 
benumb a nerve-fibre for the immediate relief of pain, and with the 
hope that the temporary paralysis may ultimately result in such nerve- 
changes as to produce a cure. 

Cold, in some form, is a popular remedy for a burn or sprain or any 
injury likely to be followed by inflammatory processes. In some cases, 
it is true, hot water or dry heat is equally efficacious, and this fact 
will be referred to when speaking of heat. (See Heat.) It may, 
however, be stated, as an almost invariable rule, that the choice of 
heat or cold is to be governed by the sensations of the patient (except 
in fevers), who will generally assert that one of the two is the more 
agreeable. 

Cold or heat causes relief of pain in inflammation by producing con- 
traction of the local bloodvessel walls. As a result, inflammatory exu- 
dates do not occur, congestion is relieved, and as the pressure on the 
nerve-filaments ceases the pulsating pain of inflammation passes away. 

A very useful remedy for the sprain of an ankle when it is a recent 
accident is to let the patient sit with the foot elevated, with a cloth 
wrung out in ice-water and an ice-bag applied over the part affected. 

In the treatment of localized pain or inflammation cold is used in 
a number of ways, largely depending in their choice on the will of 
the physician and the means of the patient. The simplest, cheapest, 
and perhaps the. most efficient method of using cold is to place cracked 
ice in a pig's or sheep's bladder or rubber bag, and, after tying its 
neck to prevent leakage, to lay it over the inflamed part, surrounding 
it with a towel, so as to prevent the moisture, which appears on the 
surface from condensation, from wetting the clothing. 

Where a very limited and comparatively transient effect is needed, 
chiefly for anaesthetic purposes, it is customary in hospital and private 
practice to use a piece of ice sprinkled with a little fine salt, and held 
against the skin by means of a towel in the hand of the physician. 
Actual freezing can often be produced very rapidly in this manner. 
Where a more rapid method is desired, sprays of various very volatile 
liquids may be driven against the part by an atomizer. One of the most 
readily employed of these liquids is ether, which is fairly effective 
if it is used in a fine spray and driven against the skin in such a way 
as to favor rapid evaporation. Another of these agents is rhigolene, 
which is one of the lightest and most volatile of the liquid products of 



558 REMEDIAL MEASURES OTHER THAN DRUGS. 

coal-tar, and is used in a spray from an atomizer in the same manner 
as is ether. Chloride of ethyl is a liquid largely used as a substitute 
for rhigolene as a local anaesthetic through the intense cold produced 
by its evaporation. The fluid is directed against the skin over the 
involved area by means of a nozzle attached to the cylinder contain- 
ing it. (See Ethyl and Methyl Chloride.) 

It is hardly necessary for the writer to repeat that, as the last three 
liquids are very inflammable, they should not be used near a light or 
fire. (See also Carbon Dioxide Snow.) 

Aside from the local effects of cold on inflammatory processes, it is 
largely resorted to for the relief of neuralgia of a superficial type, 
and has often been used for the cure of deep-seated neuralgias, as over 
the course of the sciatic nerve in sciatica. Generally, however, it is 
employed in neuralgia of the supraorbital nerve, where, owing to the 
superficial position of these fibres, the cold can readily reach them. 
The skin should be distinctly whitened and blanched, and even hard- 
ened, by the cold before its application is stopped, and if one applica- 
tion does not cause a cure, it may be repeated every day for several 
weeks in obstinate cases. Sometimes cold is used to benumb the skin 
or subcutaneous tissues in cases where a minor surgical operation is to 
be performed, but the pain of freezing an inflamed part is often as 
great as that of the operation itself without an anaesthetic. Freezing is 
valuable when the physician is using the actual cautery, and in all 
these cases may be employed as is indicated above. 

Fig. 74. 




Showing the application of the cold-water coil to the chest in croupous pneumonia or pleurisy. 
Applied to the left side, it may be so used in pericarditis in place of the ice-bag. By suction on 
the lower end of the tubing a stream of water flows from one bucket to the other, and when the 
water has been transferred the stream may be reversed by changing the level of the buckets. 

In endocarditis, and especially in pericarditis, the use of an ice-bag 
placed over the heart is a valuable remedial procedure, for it relieves 
palpitation and quiets the heart, decreases the pain and diminishes 



COLD AS A REMEDY. 



559 



the inflammation. It is also useful for cardiac palpitation and for 
the rapidly acting heart of fever during the course of pneumonia or 
typhoid fever. 

Cold affusions to the head and, better still, the use of an ice-bag 
have long been highly regarded in the treatmeut of meningitis and head 
injuries; and a hot bottle to the feet and cold to the head will often 
induce sleep in persons who habitually suffer from insomnia. This is 
particularly the case with those individuals who are wakeful from 
mental overwork. On the other hand, cases with insomnia from cere- 
bral ansemia do well if a cold plunge-bath is taken before going to 
bed, although in still other cases a hot bath is more efficacious. (See 
Heat.) The latter instances are not due to anaemia, but to nervous 
irritability, which the heat quiets, whereas the insomnia of cerebral 
ansemia is relieved by a cold plunge by reason of the increased circu- 
latory activity and equal distribution of the blood produced by the 
bath. 

When cold is to be applied to the head continuously, it is often 
convenient to employ a coil of rubber tubing and so shaped as to 
fit the vertex. One end of the tubing should reach to a tub of cold 
water on one side of the bed and the other to an empty tub on the 
other side. By sucking on one tube siphonage is established, and as 
soon as the liquid has been transferred from one tub the full tub is 



Fig. 75. 




Showing the application of the cold-water coil to the head in cerebral congestion, headache, 
meningitis, and in fevers. 



raised, the stream is reversed, and the water passes back to its former 
receptacle (Fig. 75). 

Cold water dashed or sopped against the perineum or the scrotum 
and the lumbar region is a favorite remedy with some practitioners 
for nocturnal seminal emissions, and the scrotum may be submerged 
in a tumbler of cold water for a few moments at night for a similar 
purpose. 



560 REMEDIAL MEASURES OTHER THAN DRUGS 

COLD BATHING. 

The use of a cold bath for the purpose of increasing the tone of 
the system is as old a custom as any which we have, but, like all other 
things in medicine, cannot be used without distinct indications for its 
employment, or, to speak more correctly, the absence of certain con- 
traindications. The most universal exception to its use which we find 
is that class of persons with whom prolonged bathing of any kind, par- 
ticularly when it is frequently repeated, does not agree. The writer 
is sure that a much larger number of persons belong to this class than 
is generally recognized, and he has seen cases of nervous exhaustion 
and general loss of vivacity and vitality occur as a result of too fre- 
quent bathing. This is the case more especially with daily bathers 
who soak themselves in hot or warm fresh water, particularly if the 
bath be taken in the morning. 

Before passing on to the consideration of the physiological action 
of a bath, and why and when a bath should be used, it is proper to call 
attention to the fact that a very large proportion of children who are 
bathed daily are allowed to lie and soak in the tub, and as a result 
become debilitated and fretful, only to recover when a brisk bath is 
used once or twice a week, and replaced in the interval by a nightly 
sponging with salt and whisky or salt and water. 

Through practical experience and much experimental research of 
a reliable character we now know that the following phenomena accom- 
pany the use of a cold bath in a healthy person with whom such a bath 
agrees : 

On entering the water he shivers, thinks it almost unbearably cold, 
and he gasps if the cold suddenly touches the belly-wall or an equally 
sensitive surface. In a moment, however, reaction sets in, and the 
extremities, heretofore trembling and covered with cutis anserina, 
become warmer and flushed. The pulse is increased in force and 
frequency, and the respirations are deeper and more thoroughly per- 
formed. As a result of this each portion of the body receives a more 
perfect supply of blood and feels rejuvenated. Following this stage 
of exhilaration, a third stage comes on, in which the dullness and 
depression of the first stage recur in an exaggerated degree, but this 
condition does not ensue unless the person remains too long in the 
water. If he leaves the bath while in the acme of exhilaration, the 
stimulus may remain with him throughout the rest of the day. 

The reason for the occurrence of this train of symptoms is not far 
to seek. The chilliness of the first stage shows that the great abstrac- 
tion of heat is lowering the bodily temperature, the centres for calori- 
fication in the body not producing sufficient heat for the preservation 
of the normal temperature. At first the cold drives the blood into 
the warm recesses of the body, leaving the surface cold; but in a few 
moments the system is aroused to the recognition of the fact that 
it must increase its exertions in the propulsion of blood and production 



COLD BATHING . 561 

of heat, and so with an effort it puts forth all its power, picks up each 
corpuscle in the internal organs that is hiding from the cold, and, after 
imbuing it with warmth obtained by increased heat-production in 
the sources of heat-manufacture, forces it out to the surface of 'the 
body along with its fellows, which are driven to all parts of the sys- 
tem. This is not a mere figurative way of putting the matter, for cold 
primarily always contracts bloodvessels and reflexly stimulates the 
vital centres to increased activity. 

When the bath is too prolonged, the result of overstimulation ensues, 
and the depression of the nervous system and circulation may be 
sufficient to interfere greatly with normal functional activity. 

Just at this point it becomes clear why persons "catch cold," or, 
technically speaking, suffer from local or general congestions. An 
individual who is weak may never reach the stage of stimulation just 
spoken of, because his system has not enough units of force in it to ex- 
pend them upon the functional activities named, and, as a consequence, 
the blood, which at the first shock has hurried into the internal viscera, 
is not driven back to its duty, but, sulking in its retreat like a deserting 
soldier, allows disaster and disease to ensue because its superior officer, 
the central nervous system, cannot gather together enough force or 
authority to make it do its duty. These cases present evidences, there- 
fore, of circulatory and systemic depression or have congestion of the 
lungs, liver, or other parts. In the strong person exactly the same 
state of affairs obtains in the third stage of depression, but only after 
the strength of the system has been expended in the activity of the 
stage of exhilaration. 

Cold salt baths, particularly if they are sea baths, are more stimu- 
lating and not so relaxing as is fresh-water bathing. 

The use of a cold bath after a person becomes heated is popularly 
supposed to be dangerous. On the contrary, every athlete knows 
that nothing is so refreshing and so preventive of muscular stiffness 
after severe exercise and sweating as a cold plunge- or shower-bath; 
but he also recognizes the fact that a plunge is all that is permissible, 
and it is Only the person who possesses the healthy circulatory power 
which will enable him to rebound from momentary depression to 
increased activity that should resort to such procedures. 

The tonic effect of the so-called drip-sheet in certain neurasthenic 
cases is most marked. As has been pointed out, reaction must be pro- 
duced, since it is by the stimulation of the circulation and its readjust- 
ment or equalization that good is achieved. The duration of the use of 
the drip-sheet and the temperature of the water in which it is wrung 
out are governed by the ability of the patient to react. Very feeble 
patients must be gradually trained by moderate means to the colder 
temperatures, and, if need be, may stand in a tub containing a few 
inches of warm water if there is a tendency to coldness of the feet. 

The patient being stripped, the nurse takes a linen sheet previously 
dipped in water at any temperature that is not too low for reaction 
36 



562 



REMEDIAL MEASURES OTHER THAN DRUGS 



to take place, and throws it around the patient's body and over the 
head, so that in a moment the entire surface is in contact with it. 
Then the nurse applies brisk friction all over the patient's body 
and limbs, while the latter rubs the front of the body with his own 
hands. The whole performance is over in a few moments, and the 



Fig. 76. 




Drip-sheet wrung out and thrown about the patient, who rubs himself in front while the 
attendant applies friction to the back of the body and limbs. 



patient should then lie down, be lightly covered, and rest. Such a 
drip-sheet will often be a cure for insomnia depending upon faulty 
cerebral circulation or nervous tension. In other instances it seems 
to be stimulating and to arouse dormant functions. Once a day is 
usually sufficiently often to use it, and when treating neurasthenics 
the morning is generally the best time to employ it unless it is designed 
to cause sleep (Fig. 76) . 



COLD BATHING 563 

Cold in Fevers. 

The proper manner to employ cold water externally in fever should 
be thoroughly understood. It may be used at varying temperatures, 
according to the effect desired, such as cool, moderately cold, and very 
cold. 

Very commonly in the course of a fever the patient is restless, 
uncomfortable, and sleepless, yet has not a temperature fraught 
with harm. Such a case may be sponged with tepid water or with 
alcohol and water, or salt and whisky, with great benefit in the pro- 
duction of sleep, the reduction of fever, and the advantage of nervous 
quiet. Sometimes the sponging is successful when used only over 
the arms and legs, but more frequently it should be extended at least 
to the spinal column. 

If tepid sponging does not lower the fever in a given case, then 
ordinary cool tap-water should be employed; and it is well to remem- 
ber that the secret of successful sponging lies in the use of a sponge 
not saturated to overflowing, but only sufficiently wet to leave a thin 
film of moisture on the skin, which cools the patient by its rapid evapo- 
ration and does not wet the bed-clothes. 

When we come to a study of the use of cold water in prolonged and 
severe fevers we find that its use is now universally recognized as the 
proper treatment, and with good reason. At one time it was believed 
that all the good results from cold bathing were due to the reduction of 
the fever, but it is now known that this is the least important effect of 
the bath except when there is such a hyperpyrexia that there is danger 
from that source. The benefit derived from the external use of cold 
water in infectious fevers rests upon the stimulation of the vasomotor 
system and general circulation, so that local stasis or congestions of 
blood do not occur in vital organs, in the stimulation of the processes 
of oxidation and nutrition, and in the elimination from the body by 
the skin and kidneys of toxic materials. Further, the more frequent 
cleansing of the skin aids its normal function, prevents chafing and 
bed-sores, and lowers the temperature by aiding in the dissipation of 
heat directly and through the sweat, which, even if imperceptible, is 
an important factor in reducing body-heat. 

Whenever cold is used for the reduction of fever and applied to the 
entire body, it should be applied rapidly and be accompanied by active 
rubbing of the skin of the entire body to bring the hot blood to the sur- 
face and to gain the valued effects of massage. As a rule, the water 
should be used at one temperature, and better results will be obtained 
if it is cold enough to produce something of a shock to the circulation 
and nervous system, for the effect sought is the production of a 
"reaction" — that is, a redistribution of the blood and an awakening 
of all the vital processes. For this reason the writer does not approve 
of graduated baths — that is, the use of water which is gradually cooled 



564 



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566 REMEDIAL MEASURES OTHER THAN DRUGS 

while the patient is being bathed. The whole idea of the cold-bath 
treatment of fever is to produce the reactive stimulating effect sought 
by the well man who takes a sea bath. Consequently individuals too 
feeble to react should be bathed in slightly cooled water at first, and 
the temperature of the water reduced each day a few degrees until it 
is quite cold. The exact degree of cold depends upon the need of the 
patient as stated below. 

Fever is then to be reduced by cool sponging, in old and feeble 
patients using water at 90°, 80°, or 70° F., according to the ability to 
react and the needs of the patient. Friction is to be used with one 
hand while the sponging is done with the other. 

If the patient is young enough and sufficiently strong to react, then 
the water used should be from 70° to 32° F., according to the needs 
of the case; and if the fever is persistent and difficult of reduction, 
the nurse may rub a piece of ice over the skin rapidly, applying friction 
constantly with the other hand. 

The patient should always be stripped and laid on a blanket spread 
over a rubber sheet which has been placed to protect the bed. 

It is essential when sponging is used that more of it be applied 
to the back than the front of the body, for at the back the great muscles 
and thick skin retain the heat, and these parts are not cooled if only 
the front of the body is sponged. Further, the posterior surfaces are 
the ones apt to be congested and sore from the dorsal decubitus, and 
therefore need the stimulant effect of the bath, as do the kidneys and 
other deeply situated organs. That this treatment is of value in those 
who react is shown by the marked redness of the skin, the improvement 
of the circulation and respiration, and the cleared mind. 

The use of the ice-rub with a piece of ice weighing about two 
pounds held in the nurse's hand requires more care than does the 
immersion bath, but I have yet to see the case of typhoid fever, after 
the first week, in which this plan failed to reduce the temperature if it 
was properly employed. Indeed, I have learned that when this method 
fails it is because the nurse does not know how to use it. The rubbing 
with the ice and with the other hand must be brisk and produce 
reaction. 

In some cases where sponging is not efficient the patient may be 
placed on a small canvas cot placed by the side of the bed and covered 
by a large rubber cloth, which, by being raised at the head and de- 
pressed at the foot, forms a channel for the water. Over this, again, 
is placed an ordinary sheet. The patient, after being stripped, is 
laid upon this sheet, which is then folded over him, and a spray from 
an ordinary watering-pot for flowers allowed to play upon his body 
from head to feet. The temperature of the water depends upon the 
effect required. The bed should be so arranged that the water will not 
remain in puddles under the patient, but drain off into a bucket at 
the foot. The sheet being wet allows evaporation to go on, and a 



COLD BATHING 567 

rapid fall in the fever results. It is of the greatest importance that 
the attendant lightly but briskly rub the patient all over with the 
hands during this bath, so as to bring the blood to the surface and 
prevent internal congestions. 

If the fever cannot be reduced to 101° F. by the methods of bathing 
just detailed, the patient should be subjected to the cold plunge 
or tubbing, the so-called "Brand bath," which has been employed 
almost exclusively in typhoid fever. The chief object sought by its use 
has already been described in discussing the effect .of sponging. This 
object is reaction. 

The method consists in immersing the patient every three hours, if 
his temperature reaches 102° or 102.5° F., in a bath-tub of water at 
70° F. and allowing him to remain there under friction for fifteen or 
twenty minutes, or until his temperature is reduced to 101° or 100° F. 
Before the patient enters the tub he is often given \ to 1 ounce (15.0- 
30.0) of whisky in a little milk or water to prevent depression. The 
patient will generally complain bitterly of the cold, particularly at first, 
and will also appear blue and chilly after the bath, but these signs are 
not so dangerous as they are alarming. If there be persistent and 
prolonged coldness after the bath, then hot bottles may be applied to 
the feet and a little whisky or brandy given. During all kinds of 
bathing an ice-bag should be kept to the head to prevent cerebral con- 
gestion. 

Fig. 78. 



Bath stretcher. (F. E. Hare.) 

When the tub is used, it should always be placed near the patient's 
bed, so as to avoid unnecessary disturbance and muscular effort, 
for his strength must be conserved. 

In using the Brand bath, a patient should be lifted with care and 
gentleness from the bed to the tub. The water in the tub should be 
deep enough nearly to cover his body, and yet not so deep as to float 
him in the tub so that he feels uncertain of his position and has to con- 
tinually exert himself to keep his head above water. The lifting of a 
full-grown man into a tub, unless some mechanical aid is employed, 
requires several assistants, and, even when they are present, is very 
often a strain not only upon the nurses, particularly if a number of 
patients have to be bathed, but upon the patient as well. It is very 



568 



REMEDIAL MEASURES OTHER THAN DRUGS 



important that patients should not exhaust themselves by making 
efforts under these circumstances. A number of devices have been 
invented for the transfer of the patient from the bed to the bath. 



Fig. 79. 




The use of F. E. Hare's bath stretcher. First stage. 
Fig. 80. 




The use of F. E. Hare's bath stretcher. Second stage. 

Probably the simplest and best is that employed by F. E. Hare, of 
Brisbane, Australia, as it is inexpensive and can be employed by two 
persons unless the patient is unusually heavy. It consists, as shown in 



COLD BATHING 
Fig. 81. 



569 



■iiiiiiiiii^^ . . jBi 





The use of F. E. Hare's bath stretcher. Third stage. 
Fig. 82. 




The use of F. E. Hare's bath stretcher. Fourth stage. 

the accompanying figures, in a perforated board, from which the water 
readily drains when the patient is lifted from the bath. This board 
has a loose piece at the top, which by resting on the head of the tub 



570 REMEDIAL MEASURES OTHER THAN DRUGS 

prevents the patient's face from being immersed. A rubber sheet 
having been placed on the bed by the side of the patient, the board 
is laid on top of it, and the patient is then readily slid by a lateral 
movement on to t the board, lifted up, and immersed in the tub. After 
the bath is over, the board is lifted, with the patient upon it, as high 
as the edge of the tub, a loose piece of board is slipped transversely 
across the foot of the tub, and on this and on the head of the tub rests 
the board upon which the patient is lying. In a few minutes the 
excess of water drains off into the tub, and the board is then lifted on 
to the patient's bed, which is still protected by the rubber sheet. The 
patient is then slid off from the board on to the bedding and the neces- 
sary handling is completed. 

On the removal of the patient the surface should be gently dried 
with towels, and the bed-clothing consist of only a sheet, or a sheet 
and one blanket in cold weather. Above all things, it must be remem- 
bered that the patient is not to be wrapped in a blanket, and not only 
this, but that he must not be rolled in a blanket while still in a wet 
sheet. 

The wet sheet, if surrounded by a blanket, soon places the patient 
in a typical Russian or warm moist bath, calculated to raise instead 
of lower the fever. 

When a patient comes under observation as late as the third week 
of typhoid fever the cold bath is contraindicated, as a rule, because 
the patient does not react, owing to his feebleness. If the bath is 
used from the beginning of the illness, it may be used all through the 
attack, as the system is then trained to react and is rarely so asthenic. 
Other contraindications are intestinal hemorrhage, nephritis, and great 
cardiac feebleness, but pneumonia is thought by some not to be a 
contraindication. With this view the writer disagrees. This bath is 
contraindicated in croupous and catarrhal pneumonia. 1 

The fever of enteric fever does not readily yield under the use of the 
bath in the first days of its course, whereas that of other maladies does 
do so. This is an important differential point. 

All cases of typhoid fever should receive the cleansing and reactive 
effects of sponging and rubbing at least once a day, even if the fever 
is not sufficiently high to need reduction. 

Whenever cold is used in febrile cases a thermometer should be 
placed in the mouth or pushed deeply into the rectum, and the fall in 
the temperature watched. As soon as it reaches 101° or 100° F. the 
bath must cease, lest the fall continue, reaction fail, and collapse ensue. 

Where sunstroke (thermic fever) is present the patient may have 
ice rubbed over his body or be put directly into a bath-tub of ice- 
water; but in any event the attendants must rub the patient's skin to 
bring the hot blood to the surface and prevent congestions. Cold 

1 For a careful resume of the ' 'Real Value of the Brand Bath in Typhoid Fever," by the author 
and Dr. C. A. Holder, see the Therapeutic Gazette, March 15, 1898. 



LOCOMOTOR ATAXIA AND MYELITIS 571 

water may also be injected into the bowel in cases where the skin is 
cold but the central temperature very high. (See Enteroclysis.) 

The treatment of rheumatic hyperpyrexia by cold is quite as suit- 
able as is this treatment of other fevers when the hyperpyrexia is so 
excessive as to endanger life. 

Baruch, the apostle of hydrotherapy, has expressed some views in 
the following emphatic "Dont's," with which the author most heartily 
agrees : 

Don't bathe with cold water to reduce temperature, but to refresh 
the fever-stricken patient. 

Don't permit cyanosis or chattering of teeth; stop! 

Don't stop bathing because patient complains of chilliness, unless 
the teeth chatter. 

Don't raise bath temperature on the latter account; shorten bath 
and increase friction. 

Don't neglect friction during every cold procedure; it prevents 
chilling. 

Don't disregard the well-ascertained fact that the Brand bath (of 
65° to 70° F. every three hours when awake, with active friction) is the 
ideal bath for typhoid fever only. 

Don't give up cold bathing because the ideal bath is not obtainable; 
other procedures are useful. 

Don't use the ice-coil to the abdomen; it has no refreshing effect 
and renders the skin beneath it cyanotic. 

Don't lose sight of the fact that the chief aim of all cold procedures 
is reaction. 



CO-ORDINATED MOVEMENTS FOR TREATING LOCOMOTOR 
ATAXIA AND MYELITIS. 

This plan of treatment is based upon the fact that great improve- 
ment in locomotion on the part of ataxic patients can be produced by 
causing the patient to make certain definite movements, the object of 
which is to re-educate his co-ordinating power. The power of co- 
ordination is lost partly by reason of the disease in the nerves and 
spinal cord, and partly because the patient has become bedridden, 
so that his otherwise healthy tissues waste from disuse. Definite 
exercises in such cases perhaps train collateral nerve-centres and 
nerve-tracts to do work not usually part of their function. In any 
event, such patients often greatly improve under this procedure. 

It is vitally important that the various movements should be made 
slowly and with as great nicety as possible. 

Exercises for the Lower Limbs. — The patient lies on his back on 
a firm couch and slowly lifts his fully extended leg until he touches 
with his toes the finger of an attendant, who holds his hand at a dis- 



572 



REMEDIAL MEASURES OTHER THAN DRUGS 



tance of from eighteen inches to two feet above the bed. These exer- 
cises should be repeated several times with each leg. 

Next, the patient completely flexes the leg on the thigh, and then 

Fig. 83. 




mmmim. 




Showing the pigeon-holes into which the patient puts his heels when training his co-ordination 
and muscle-sense in locomotor ataxia. 

the thigh on the abdomen. After this the limb is slowly extended 
until the toe once more touches the finger of the attendant, the leg 
being elevated at the same time that it is extended. After making this 
contact the extended limb is slowly lowered until it rests on the bed. 

A third exercise consists in having a board made with pigeon-holes 
attached to it, the tops of the pigeon-holes being taken off. A dozen 
of these holes should be made, and either lettered in the order of the 
alphabet or numbered consecutively. The patient lying on the back, 
with the heels resting in two of these pigeon-holes, is directed to 
raise a leg and to lower it so that the right heel will come down in the 
pigeon-hole named by the attendant; so that if the right heel is resting 
in pigeon-hole 1, it may be placed in pigeon-hole 4; and afterward 
the left heel, which may be resting in pigeon-hole 7, is placed in pigeon- 
hole 6. It will be readily seen that following these directions trains 
the co-ordinative faculty. The edges of the pigeon-holes should be 
smooth, and perhaps padded, to prevent the heel from being injured 
by striking against them. 

The standing exercises consist in endeavoring to stand with the 
eyes closed and the feet close together, and in trying to stand on one 
foot with the eyes open or closed. 

Another exercise is to paint a black stripe a foot wide across the 
floor of a room, and to direct the patient to walk along this stripe with 
or without support, being careful to keep his feet within its limits. 
He will usually do better with bare feet than if he has his shoes on. 
In taking this exercise the patient should be directed to bring the 
foot down in the natural position, and not upon the heel, as is so 
commonly done by tabetics; and also he must not evert the toes 
too much in walking, as is so commonly the habit. As the patient 
improves, the stripe upon which he walks may be narrowed. 

The next walking exercise consists in going up and down stairs. 
It is well to build a flight of stairs, consisting of five or six steps, with a 
platform, which is so securely built that there is no danger of a fall. 
A balustrade or railing is put on each side of the steps for lateral sup- 
port, and the patient is then made to ascend and descend the steps. 
Care must be taken that he mounts the successive steps by a proper 
contraction of his quadriceps rather than by pulling himself up by the 



CO UNTERIRRITA TION 



573 



aid of his hands. Many tabetics 
simply place the leg in a rigid posi- 
tion, and then use their arms to ele- 
vate themselves to the next step. 

Still another exercise is to place 
the patient in an arm-chair and 
teach him to lower himself into 
the chair without touching the 
arms of the chair with the hands. 

It is vitally important that these 
exercises shall not be continued 
until the patient is unduly fatigued. 
He should simply be slightly tired 
at the most, and usually a quarter 
of an hour, twice or thrice a day, 
is a sufficient length of time for 
the treatment. Exhaustion is dis- 
tinctly harmful under these cir- 
cumstances. The patient should 
be urged to respond promptly to 
directions, as alacrity is important 
in training the co-ordinate faculties. 

Somewhat similar exercises may 
be devised for the arms in cases 
where the upper limbs are ataxic 
as well as the lower ones. 

COUNTERIRRITATION. 

Counterirritation is a term ap- 
plied to the use of substances irri- 
tating to the surface with which 
they come in contact, and is em- 
ployed for the purpose of influ- 
encing morbid processes in more 
or less distant parts or of affecting 
the general system. It has been 
thought that this method savors 
of the doctrine of "like cures like," 
but in reality it is based on sound 
physiological laws. 

The entire basis for the employ- 
ment of counterirritation rests upon 
reflex action, or the conduction of a 
nervous impulse to a centre, which, 
when so stimulated, sends out an 
impulse to the part of one body 
which is diseased. 



Fig. 84. 




To illustrate the nervous pathways by 
which are exercised the effects of counter- 
irritation. Diagram giving a schematic rep- 
resentation of the course of the autonomic 
(sympathetic) fibres arising from the thor- 
acico-lumbar and sacral regions of the cord. 
The preganglionic fibre is represented in dot- 
ted lines, the postganglionic in solid lines. 
The arrows indicate the normal direction 
of the nerve impulses or nerve conduction. 
S.c, Superior cervical ganglion ; I.e., inferior 
cervical ganglion ; T, the first thoracic gang- 
lion ; Sp., the splanchnic nerve ; C, the semi- 
lunar or celiac ganglion; m., the inferior 
mesenteric ganglion; h., the hypogastric 
nerves; N.E., the nervus erigens. The 
numerals indicate the corresponding spinal 
nerves. (Howell's Physiology.) 



574 



REMEDIAL MEASURES OTHER THAN DRUGS 



The use of counterirritation may be divided into four parts or pur- 
poses: the first is for affecting inflammations or congestions; the 
second, for causing the absorption or removal of inflammatory de- 
posits after true inflammation has ceased; the third purpose is for 
the relief of pain; and the fourth for the effect which can be exercised 
upon the general system by blisters in systemic disease. 

In the same manner that we. divide the indications for counter- 
irritation into four parts, so can we also divide its forms into three 



Fig. 85. 



f*rg4 




Showing the areas in which blisters are to be placed: P, pericarditis; A, appendicitis; 
L, laryngitis; V, vomiting or gastritis; P L, pleuritis; R, inflammation in joint. 



varieties according to their severity. The most severe are the caustics 
or escharotics, the next the epispastics or blisters, and finally the rube- 
facients or reddeners. 

The proper manner of employing a counterirritant to affect inflam- 
mation is not to apply it directly to an actually inflamed area, but a 
little to one side of it, or at a spot known to be connected intimately 
with the diseased area by nerve-fibres. 

Thus, it is well known that in diseases of the eye the blister should 
be applied back of the ear, and that in abdominal neuralgia or in 



CO UNTERIR RITA TTON 575 

pleurodynia the best results are reached, not from the application of a 
blister to the spot where the pain is felt, but to the point upon the 
vertebral column where the nerve at fault takes its exit. The reason 
for this is that pain is always referred to the peripheral end of an irri- 
tated nerve, and pleurodynia or abdominal pain often arises from verte- 
bral disease or inflammation about the spinal ligaments or the foramina 
of exit for the nerves. In a similar manner we sometimes apply a 
blister, in the early stages of hip disease, not to the knee or ankle, 
where the pain is felt, but at the seat of the trouble:— namely, the hip. 
Counterirritation is contraindicated by the presence of any acute 
inflammation directly under the spot where it is proposed to place a 
blister; that is, if any reddening of the skin is present, the blister or 
other form of irritation must not be applied there. If used at all, it 
must be some little distance away, or a series of small flying blisters 
should be placed around the inflamed zone. A flying blister is one 
which is small in area — say as large as a Lima bean — and of com- 
paratively slight action, the blister healing rapidly after its primary 
effects have passed by. 

Among the inflammatory infections in which counterirritation has 
been found very serviceable may be mentioned pleurisy, pneumonia, 
iritis, and synovitis (rheumatic or traumatic). A host of more sub- 
acute or chronic inflammations are also benefited by this measure, 
some of which are chronically enlarged joints and inflamed glands. 
In all these states the blister or, more rarely, a rubefacient is to be 
resorted to ; and while it is true that many of these conditions are ac- 
companied by fever, and that fever is generally held to be a contraindi- 
cation to the use of a counterirritation, blisters undoubtedly do good 
in such states. In pneumonia or pleurisy, in the very earliest stages 
of the disease, a cantharidal blister of the size of a silver dollar may be 
applied near the spot where the pain is most felt or on the back near 
the spine (Fig. 86) . When a joint is inflamed, the blisters should be at 
some distance from the seat of the swelling, although it is often useful 
to place the counterirritant on the inner or outer aspect of the knee- 
joint if the skin is not reddened. 

Where an inflammatory process is chronic and resists cantharidal 
blistering, then resort is often had to more severe forms of counter- 
irritation by means of the red-hot — not white-hot — iron, or the use of 
escharotics, such as caustic potash or caustic soda or arsenic. The 
reason for using these is that they all cause so much tissue-change 
in the part that the counterirritation is very prolonged. Sometimes 
antimonial ointment has been applied constantly until a slough forms, 
to accomplish the same purposes. 

For the removal of the products of inflammation resort is had to 
cantharidal blisters or drugs possessing powers as local irritants and 
at the same time as alteratives. Thus, in pleurisy with effusion it is 
very proper to employ a number of small blisters if the effusion 
has a tendency to remain unabsorbed, but if the pleural surface is 
covered with a fibrinous exudate the blister can do little good as far 



576 



REMEDIAL MEASURES OTHER THAN DRUGS 



as the effusion is concerned until this is absorbed. Some have thought 
that the absorption which follows is due to the abstraction of serum 
which takes place in the bleb formed, but this is a mistaken idea, as 
one often sees an effusion absorbed which far exceeds in quantity the 
amount of liquid in the blister. Under these circumstances the spot 
for applying the blister is, as a rule, immediately under the arm, about 
two or three inches below the axilla. The blister, while it is useful 

Fig. 86. 




Showing the areas in which blisters are to be placed: O, earache or vertigo; M, meningeal 
inflammation or effusion at the base of the brain; H, haemoptysis; P L, pleuritis; /, intercostal 
neuralgia; K S, renal or spinal irritation; R, rheumatism or inflammation in joint. 

in causing absorption in chronic effusions and deposits about joints, 
is not so good as are alterative irritants; for example, iodine, which 
in the form of a thorough application at one sitting until the skin is 
black — not yellow or red — is often of service. In very chronic cases 
iodine ointment, alone or with lard, may be rubbed into the parts 
with advantage, care being taken to stop its use for a day or two as 
soon as the skin reddens. This same treatment is also useful in 
treating enlarged glands in the neck and elsewhere before pus forms. 



CO UXTERIRRLTA TION 577 

The treatment of acute and chronic inflammatory processes by blisters 
is not as frequently resorted to at this time as it formerly was. 

Much difference of opinion exists as to the proper treatment of the 
blister formed by cantharides. Where the blisters are small — that is, 
the size of the tip of a finger — they may be allowed to break of them- 
selves, and then be dressed with dry cotton; if they are large, the blebs 
should be punctured at -their most dependent part with an antiseptic 
needle and dressed with dry absorbent cotton, as by so doing the new 
skin rapidly forms underneath and is soon able to carry on its normal 
functions. The proper treatment of the blister while it is forming is 
to apply a poultice, which will decrease the pain and aid in the for- 
mation of the bleb. 

One of the best treatments for epididymitis is to paint the scrotum 
black with many coatings of a strong solution of silver nitrate or tincture 
of iodine, to insist on absolute rest in bed, and to resort to the local use 
of cold. The testicles should also be supported by a suspensory or 
adhesive strips during this treatment, and aconite given if fever is 
present. 

For the relief of pain resort is very commonly had to the rube- 
facients rather than epispastics, since the more moderate applications 
are equally effective in most instances, and do not leave skin lesions 
behind to remind the patient of his illness. 

Every one who has had stomach-ache and remembers the relief 
obtained by the use of a mustard plaster or spice plaster recognizes 
the value of this means of obtaining relief, and headaches are often 
amenable to similar treatment. These headaches may be neuralgic or 
due to dyspepsia or to cerebral anaemia or congestion, but counterirri- 
tation will nevertheless do good. A mustard or capsicum plaster may 
be applied to the forehead or to the nape of the. neck. If neuralgic, 
a little menthol or oil of peppermint may be applied over the course 
of the nerve, which application, if it be supraorbital, will require care 
lest the oil gain access to the eye. 

For the treatment of pain in the belly or chest or elsewhere we have 
four means of producing counterirritation in the shape of rubefacients 
the first is mustard; the second, capsicum; the third, the turpentine 
stupe; and fourth, the spice poultice. 

The mustard plaster should be made by mixing mustard flour with 
warm vinegar or water, and adding varying proportions of ordinary 
flour to modify its action. If the skin is tender, half mustard and 
half wheat flour may be employed; or if a child is to be treated, the 
proportion should be only one-fourth mustard. The plaster is made 
by placing a piece of stout paper on a table and putting over it a piece 
of heavy muslin or linen. On this is smeared the mustard mass, and 
over this is placed a piece of thin linen, which prevents the poultice 
from adhering to the skin and modifies the burning according to its 
densitv. By folding the edges of the paper so that it resembles a 
picture-frame we have at hand a cheap, effective, and strong plaster, 
the back of which is supported by the paper. 
37 



578 REMEDIAL MEASURES OTHER THAN DRUGS 

The spice plaster is made by mixing equal parts of allspice, cloves, 
cinnamon, and nutmegs, and adding thereto one-half part of black 
pepper. These constituents are made into a homogeneous mass by 
using a knife-blade to mix them, and are then sewed in a bag which 
is quilted to prevent sagging of the contents. One side of the poultice 
is now wetted with warm brandy, whisky, or vinegar and applied 
to the part desired. If the skin is tender, the proportions of pepper 
and cloves should be decreased. This plaster may be allowed to 
remain over the affected part for hours or even days, and is very 
useful in the treatment of gastric catarrah and indigestion, particularly 
those forms occurring in children. 

The turpentine stupe (see Turpentine) is not to be allowed to 
remain very long on the skin, as it may blister a tender cuticle, and 
the capsicum plaster may be so active as to produce unbearable pain. 

The proper way of treating all such burns from counterirritation 
is to apply simple cerate, petrolatum, or sweet oil, to which may be 
added carbolic acid in the proportion of 1 : 100. The carbolic acid 
acts not only as an antiseptic, but also as a local anaesthetic, while 
the oil serves as a protective from contact with the air. 

CUPPING. 

Cups are used in two forms, the dry cups and the wet cups. The 
first depend almost entirely upon their counterirritant effect for their 
therapeutic value. A hollow glass bulb fitted with a valve or stopcock is 
placed upon the skin and exhausted by means of a small hand pump. 
The stopcock is turned to prevent the entrance of air and the cup 
allowed to remain until sufficient air leaks into it to overcome the 
vacuum and let it fall off. Several such cups placed over the bases 
of the lungs or kidneys relieve congestion and stasis in these organs. 
Dry cups are often employed, ana are valuable aids in treating the 

Fig. 87. 



Dry cups applied to the chest, as in a case of pulmonary oedema, the early stages of 
pneumonia, or diffuse bronchitis. 

conditions named. Dry cups are not to be used in acute pleurisy or 
peritonitis lest they injure the parietal serous membrane. 



DISINFECTION 579 

A wet cup is applied as is the dry, but before it is placed on the 
skin the cuticle is incised by a scalpel in several places so that it will 
bleed freely when suction is produced in the cup. It is, therefore, both 
counterirritant and depletant, and is not to be used in feeble persons 
who cannot stand loss of blood. 

DISINFECTION. 

Before discussing the subject of disinfection, attention must be 
directed to what is meant by the terms employed when speaking of 
this subject. At present we recognize that the word "germicide" 
is applicable solely to agents capable of killing the lower forms of 
life, whereas "antiseptics" are substances which render material 
with which they come in contact so antagonistic or unsuited to germ- 
development as to render it impossible, at least in an active state. To 
use a simile: the killing of the inhabitants of a district by shooting 
them would stop all growth and be germicidal, whereas the destruction 
of the crops in those same parts would only be antiseptic; or, in other 
words, the people might remain, but would starve to death. (See 
article on Antiseptics.) 

We speak of germicides as disinfectants, but never of antiseptics 
as disinfectants if we use these terms correctly, but "germicide" and 
"disinfectant" are synonymous words. 

From what has just been said, it is evident that when dealing with 
filth we should always resort to disinfectants rather than antiseptics, 
for although the latter are good, the former are better. 

We have three ways of destroying germs which are particularly 
useful: The first is the total destruction not only of the germs, but 
also of their resting-place, by means of fire, which may be used in 
the case of old furniture, mattresses, and similar materials, and which 
may be extended to everything which has been about the patient if 
it is necessary to stamp out a brisk epidemic before it can get well 
under way; the second is the use of moist heat in the form of super- 
heated steam, or, better still for common purposes, the use of boiling 
water; and, thirdly, by means of disinfectant materials which have a 
proved reliability. 

Moist heat in the form of superheated steam is infinitely preferable 
to dry heat, but as superheated steam cannot be readily obtained, 
physicians usually direct clothing to be boiled for at least two hours. 

Very often the bed-clothes are taken from a sick-room, trailed 
through the house, and finally deposited at any spot until a con- 
venient time for boiling them occurs. This is radically wrong and 
capable of causing a widespread distribution of the disease. In all such 
cases the bed-clothes should be rolled off the bed in a bundle and com- 
pletely submerged in a bucket or tub of boiling water, or, better still, 
in a corrosive sublimate solution of the strength of 1 : 1000, before 
they are taken from the room. This tub is now to be carried at once 
to the fire, and the clothes lifted out dripping wet and plunged into a 
clothes-boiler in which the water is actively boiling. The lid of the 



580 REMEDIAL MEASURES OTHER THAN DRUGS 

boiler is at once to be put on to increase the heat and prevent the 
escape of any germs in the steam or in the hot air which arises from 
the surface of the water. The active boiling should be continued for 
one or two hours, and water be continually added to prevent scorching 
the contents of the boiler. 

It is important that food be not cooked on the stove at the time the 
clothes are being boiled, and no food should be in the room. 

If boiling cannot be resorted to for any reason, the clothes may be 
soaked in a 1 : 500 solution of corrosive sublimate, or formaldehyde 
solution, although neither of these is so sure a method of disinfection 
as boiling. 

The care of a room after it has been occupied by a case of infec- 
tious disease is of great importance, and is generally sadly mismanaged. 
Disinfection is best accomplished by formaldehyde gas, which may 
be set free in one of two ways: namely, boiling the official solution by 
means of an alcohol lamp or other source of heat, whereby the gas is 
set free, or by the addition of permanganate of potassium to the official 
solution. The latter is a more expensive, but safer method, as it avoids 
the danger of fire in the tightly closed room. To satisfactorily disinfect 
a room containing 1600 cubic feet, 240 grammes of potassium per- 
manganate are placed in a large pail and 1 pint (500 mils.) of the official 
formaldehyde solution is placed upon it. This instantly results in a 
furious ebullition, which may cause the contents of the bucket, unless 
it is a very large one, to overflow. The volume of gas set free is so 
great that before the mixture is made the physician should have every- 
thing prepared so that he can at once leave the room. (See Formic 
Aldehyde.) The gas does not injure dyed stuffs. 

When formaldehyde is used, the following rules should be fol- 
lowed : 

1. All openings in the plaster or in the floor, or about the doors 
and windows, should be caulked tight with cotton or with strips of 
cloth. 

2. The linen, quilts, blankets, carpets, etc., should be stretched 
out on a line, in order to expose as much surface to the disinfectant as 
possible. They should not be throw r n into a heap. Books should be 
suspended by their covers, so that the leaves are separated and freely 
exposed. 

3. The walls and floor of the room and the articles contained in it 
should be thoroughly sprayed with water. If masses of matter or 
sputum are dried on the floor, they should be soaked with water and 
loosened. No vessel of water, however, should be allowed to remain 
in the room, as it will absorb the gas. 

4. One hundred and fifty mils. (5 ounces) of the commercial 40 per 
cent, solution of formaldehyde for each 1000 cubic feet of space should 
be placed in the generating apparatus. 

5. The room thus treated should remain closed for at least ten 
hours. If there is much leakage of gas into the surrounding rooms, a 



DISINFECTION 581 

second or third introduction of formaldehyde at intervals of two or 
three hours should be made. 

As an additional measure of disinfection all movable objects are to be 
taken out of doors into the fresh air, and then the floor, sills, and casings, 
are scrubbed with hot water, and soap. The water remaining in tne 
bucket should afterward be boiled to kill the germs which may be in 
it. This scrubbing being accomplished, the same surfaces should be 
scrubbed a second time with a solution of corrosive sublimate (1 : 1000 
or 1 : 500) and left wet, so that the mercury salt may remain on them. 
Cracks and crannies are to receive particular attention. After this 
is done the floor should be flushed with a solution of formal- 
dehyde. 

An essential disinfectant for all diseases is good ventilation. Not only 
should as much air as possible be allowed to enter the sick-room, but 
after the patient has vacated the premises the windows should remain 
open for weeks if possible. Fresh air dilutes germs as fresh water 
dissolves or dilutes dirt. 

The question as to which are the best disinfectant substances is 
one that has attracted the attention of physicians and original inves- 
tigators for years. The result of a vast amount of study and expe- 
rience shows that formaldehyde in solution or in the form of gas is 
the best of all disinfectants (see also Formaldehyde, Part II.), and that 
next to formaldehyde in value is corrosive sublimate in the proportion 
of 1 : 250 to 1 : 500, or even weaker, but that for cheapness, activity, 
and general usefulness chlorinated lime is better still. The disad- 
vantages in the use of corrosive sublimate lie in its ready decompo- 
sition, its formation of an inert albuminate of mercury when albumin 
is present, its inertness where lead pipes are present, and, above all, 
its expense. Chlorinated lime depends almost entirely upon its chlorine 
for any disinfectant power which it may possess. Chlorine gas itself is 
not readily handled, but the lime enables us to put it where we will. 
It cannot be employed to disinfect colored fabrics, as it bleaches them. 
None of these objections hold good against formaldehyde. 

Whenever chlorinated lime is bought, the physician should see that 
all the chlorine has not departed from it, as much of the material kept 
in the stores is so old as to be almost worthless. 

For scrubbing floors, chlorinated lime may be made into a solution 
by adding a cupful to a bucket of water, and in privies it may be spread 
thickly over the surface of the mass of filth. 

It is useless to place chlorinated lime in saucers around a room for 
the purpose of disinfecting the air, as the amount of chlorine to the 
volume of air to be disinfected is as nothing. 

Copperas, or sulphate of iron, while largely used as a disinfectant 
is in reality only an antiseptic. 

Disinfection of the discharges of the patient suffering from an 
infectious disease is an important duty to be remembered. (See 
Urotropin or Hexamethylenamine.) The urine and feces should 



582 REMEDIAL MEASURES OTHER THAN DRUGS 

always be received in a vessel containing enough corrosive subli- 
mate solution (1 : 500) to kill all germs, and to prevent their escape 
into the air or into water or food when the discharges are thrown 
away. The disinfectant should be placed in the bed-pan before, not 
after, it is used. 

The bed-pan or chamber should not be allowed to stand in the 
room, but be removed and emptied at once in such a manner that its 
contents cannot contaminate any water or food. Its contents should 
not be thrown upon the ground, as the air will dry them and cause 
the germs to be disseminated in the form of dust. 

In very contagious diseases bathing or swabbing off the patient 
with weak antiseptics may be tried. Thus 1 : 10,000 solution of bichlo- 
ride of mercury may be used and the patient afterward wiped off with 
a wet towel. In other instances a 1 : 500 solution of carbolic acid in 
sweet oil may be employed to soften the skin, allay itching, and dis- 
infect the patient. This is particularly useful in scarlet fever. 



ENTEROCLYSIS. 

Enteroclysis, or the washing out of the bowel by means of large 
and slowly injected clysters for the purpose of medicating or cleansing 
the large intestine, has become one of the most valuable therapeutic 
measures we possess. It is of value not only for the purposes named, 
but also for the relief of intestinal obstruction, for the maintenance of 
bodily heat by the use of hot water, and for the reduction of fever by 
the use of cold waier. 

The employment of irrigation of the colon in cases of dysentery is 
by no means of recent date. It is only, however, within the last few 
years that this method of treatment has been widely employed or 
studied. Aside from the fact that by this means we can bring medica- 
ments in direct contact with the diseased mucous membrane, there is 
no doubt whatever that the mere passage of normal salt solution at 
suitable temperatures over the bowel-wall is of value, for in this man- 
ner we remove mucus and pus, and so dilute the poisons produced 
by the germs of the disease that their further action is largely inhibited. 
In adults the use of irrigation in dysentery should be carefully carried 
out by means of an inflow and an outflow tube, the first being attached 
to fountain-syringe. The outflow tube must be large enough to 
permit of the liquid leaving the bowel with a readiness equal to that 
of its inflow, and must be so straight and patulous as to permit of the 
fluid carrying away with it from the bowel any flakes of mucus or other 
foreign matter. The inflow tube should be introduced a consid- 
erable distance into the bowel and the outflow tube placed just within 
the sphincter. The method employed in giving the injection, the tem- 
perature of the water, and the gentleness of the operation are exceed- 
ingly important, and will be discussed below. The amount of water 



ENTEROCLYSIS 583 

employed in irrigation of the bowel in dysentery is not to be measured 
by quarts, but by results. It should continue to flow in until it comes 
from the outflow tube perfectly clear, showing that our object — 
namely, thorough cleansing of the bowel — has been accomplished. 
The best medicament to be added to the water is boric acid or tannic 
acid, each of which is harmless and capable of doing much good. 
In nearly all instances in which we wish to cleanse the bowel a normal 
salt solution should be employed rather than pure water, as the latter 
tends to irritate the intestinal wall. (See Ipecac and Cinchona.) 

The question as to what is the best method of treating a case of 
intestinal obstruction by enteroclysis is one which is of interest to the 
physician as well as the surgeon. Such cases generally come into the 
hands of the general practitioner first, and it is for him to decide 
whether the surgeon shall be called in consultation. The author is 
not one of those who place much confidence in the reports of cases of 
volvulus or intussusception overcome by enteroclysis. The true indica- 
tion for rectal injections is obstruction due to impacted feces 

A very important point to be decided in connection with this sub- 
ject is the amount of pressure that can be used with the stream of water 
which is employed, the length of time during which the injection may 
be given, and, finally, the temperature and character of the fluid 
injected. As is well known, the great majority of cases of intussus- 
ception take place at the ileocecal valve, and, if not here, in the sig- 
moid flexure. Pressure by injection is therefore readily brought to 
bear on the area involved. It has been claimed that certain pressures 
will cause rupture of the peritoneal coat of the intestine, but Dr. Martin 
and the writer failed to produce this lesion in the dog by any pressure 
we could employ, since before this occurred the liquid passed through 
the stomach and mouth. To employ a pressure exceeding eight 
pounds is, however, distinctly dangerous, not because the intestinal 
wall in health will not stand this as a rule, but because it is near the 
injury line, and if any disease or softening of the bowel exist, it is 
almost certain to cause rupture. A pressure of from two to five pounds 
is, as a rule, as much as may be employed, and this pressure should 
be reached by degrees, starting the injection at such a pressure that 
the flow amounts to hardly more than trickle, and increasing the pressure 
as the antagonism of the bowel is overcome. Finally, when the bowel 
is fully distended up to the point of obstruction, the pressure on the no 
longer moving column of water may be increased, if necessary, to six 
or eight pounds by raising the bag of water not more than three feet. 
In infants, in whom invagination so often occurs, a pressure greater 
than two pounds is dangerous, and it is of vital importance that the 
pressure be employed properly, otherwise it will do more harm than 
good in several ways. As a rule, in our anxiety to give the patient 
relief at once we are inclined to use too much force and too large a bulk 
of water, and think that active force, if such a term may be used, is to 
be resorted to. Those who have seen these cases have learned by 



584 REMEDIAL MEASURES OTHER THAN DRUGS 

experience the harmfulness of such measures, and have also learned 
how great is the expulsive power of the bowel when it is excited to 
contraction. If this power be brought into activity, it will be almost 
impossible to inject fluid into the rectum. 

The dangerous practice of using a Davidson or any other kind of 
hand force syringe in the treatment of this class of cases is to be con- 
demned. Several unreported cases of rupture of the bowel and death 
from the employment of the Davidson syringe for this purpose have 
occurred, because the amount of force used was indeterminable, and 
because the fluid was injected with a jerking instead of a constant flow. 
The amount of fluid injected should be large, and if it is impossible to 
get a large amount into the bowel, it is probably because the inflow 
has been so rapid as to excite intestinal opposition or the rectal tube 
is plugged by hardened feces. 

Finally, the author cannot leave this subject without saying a word 
concerning the temperature of the injected liquid and its constitution. 
An injection of this kind goes into the very heat -citadel of the body, 
and if too cold, as it often is, produces dangerous chilling of organs 
which are ordinarily especially protected from cold by the omental 
apron and intestines. By repeated experiments, Martin and the author 
found that water at 65° F. lowered the bodily heat three degrees in 
thirty minutes. The use of colder water than this (52° F.) resulted 
in death in twelve hours, and the post-mortem showed intense con- 
gestion of the colon, which contained bloody mucus. 

The use of water of too high a temperature is also dangerous, lest 
it produce heat-stroke. Of course no one would use water hot enough 
to produce local harm, yet it is necessary to have just enough heat 
and no more. Martin and the author proved that the use of water 
at 115° F. caused in twenty-five minutes a rise of bodily temperature 
in the axilla of nearly five degrees, and developed marked symptoms 
of heat-dyspnoea. The temperature which it is right to employ we 
found to be 101° to 103° F. as the w 7 ater entered the bowel, or even 
as high as 104° F. in the water-bag if a long tube were used, as 
under these circumstances the water is rapidly cooled. An interest- 
ing result of these experiments as to heat is that when cold water was 
used it took four times as long to make the injection as when mod- 
erately warm water was employed. 

If very large injections are used, a normal saline solution of 7: 1000 
(1 drachm to 1 pint) should be employed to avoid the abstraction of 
vital salts from the intestinal wall, with consequent passage of water 
into the tissues, making them boggy, due to the law of osmosis. If 
the saline solution is stronger than this, it abstracts water from the 
bowel wall and causes irritation and thirst. Distention of the bowel 
by injection produces little if any effect on the circulation and respira- 
tion, but the passage of large amounts of warmed fluid directly into 
the closed abdominal cavity causes death rapidly. 

Rectal injections of hypotonic salt solution in the strength of 0.5 
per cent, are very useful to relieve thirst and to keep the kidneys 



GAVAGE. 



585 



active after abdominal operations and during the course of acute 
infectious diseases when there is scanty flow of urine and marked 
toxemia. (For the Murphy Drip or Proctoclysis see article on Peri- 
tonitis, Part IV; Nutrient Injections see Levulose, Part I; Feeding 
the Sick, Part III, and Diabetes Mellitus, Part IV.) 

GAVAGE. 

Gavage is a term applied to the forced feeding of patients who will 
not or cannot swallow food. The method is often employed in nourish- 




Showing the introduction of a soft catheter through the right side of the nose in the 
practice of gavage. 



ing the insane who refuse food (Fig. 88). A soft-rubber catheter is 
passed through one of the nasal chambers back into the pharynx, a 
small funnel is attached to its outer extremity, and the milk, or beef- 
broth, or other liquid food is by this means introduced into the pharynx, 



586 REMEDIAL MEASURES OTHER THAN DRUGS 

where the muscles of deglutition seize it. The term gavage is also 
correctly applied to the forced feeding of a patient by an oesophageal 
tube, as in the use of lavage. (See Lavage.) 

HEAT. 

Heat is used locally for a number of purposes in the same manner 
as is cold, and, as was stated in the article on Cold, the choice of heat 
or cold in the treatment of any acute form of inflammation depends 
almost entirely upon the wish of the patient, who generally can tell 
at once which will give him the greater comfort. 

In sprains of the ankle nothing compares to a hot foot-bath pro- 
longed for hours, the object being to decrease the pain and swelling, 
thereby regaining the use of the limb. The high degree of heat which 
can be borne by gradually increasing the temperature of the water 
by the addition of small quantities of scalding water is extraordinary, 
and the favorable results obtained are in direct ratio to the height of 
the temperature. Between these soakings the part should be dressed 
with lead-water and laudanum, and rubbed with ichthyol ointment 
or camphor liniment and laudanum. 

In spasmodic affections involving either striped or unstriped mus- 
cular fibre the local application of heat is a very useful means of relief. 
Sometimes in lumbago, or muscular stiffness in other parts of the 
body, the use of an ordinary hot laundry iron over the affected parts 
will prove of great service, the skin being covered by several layers of 
newspaper to afford a smooth surface over which to pass the iron and 
to protect the parts from too great heat. 

In chordee the best means for rapid relief, other than the use of 
drugs or general relaxants, such as amyl nitrite, is to steep the penis 
in hot water. A hot sitz-bath before going to bed is a good pro- 
phylactic against this painful complication of gonorrhoea. 

In croup of the spasmodic type the local application of a hot com- 
press, made by wetting spongiopiline with hot water, is very useful, 
or if spongiopiline cannot be had, several layers of flannel should be 
wetted, placed on the throat, and covered with wool and oiled silk so as 
to prevent the roll becoming chilled. 

Nearly all forms of pain in the eyes can be much relieved by the 
application of heat. Thus iritis, corneal irritation and ulceration, and 
pain due to eye-strain can be greatly relieved by the use of hot water 
applied by cotton pledgets frequently renewed, but never allowed to 
remain on long enough to act as warm poultices. Another method is to 
allow water as hot as can be borne to drop upon the lids from a fountain- 
syringe. The water-bag should not be more than two feet above 
the patient's head, and the fluid should drop on the eyelid from the 
distance of a few inches only. 

Where attacks of dysmenorrhwa depend upon spasmodic closure 
of the cervix, with simultaneous spasm of the fundus uteri, a hot sitz- 



HEAT 587 

bath or hot vaginal injection is useful, and this treatment is also of 
value where uterine congestion results in leucorrhcea or a sensation of 
weight in the pelvis. 

Sometimes attacks of torticollis may be subdued by applying hot 
compresses to the sternomastoid muscle. 

The local application of heat may serve to determine whether the 
inflammatory process has gone on to the formation of pus. Before 
pus is formed heat decreases the pain, it is claimed by Lewin, but 
afterward greatly increases it. 

Heat is largely used, when the skin or kidneys are torpid, to aid in 
the elimination of impure and effete materials from the blood and 
tissues. It is employed in two forms, the dry and the moist, commonly 
called the Turkish and Russian baths respectively, and may be taken 
under home arrangements or in one of the establishments found in all 
large cities. 

The Turkish bath consists of a series of rooms ranging in tempera- 
ture from 100° to 150° F. or more, into which the individual passes 
successively until the hottest room is reached. In each chamber 
he lingers until the system becomes accustomed to the high tempera- 
ture, and perspiration is well established before he enters the hottest 
room, where he remains for a varying length of time according to 
the advice of his physician or his own whim or comfort. The rule 
governing his stay is that he must leave it at once if any sense of oppres- 
sion is experienced or if perspiration does not flow freely. Some- 
times a glass of cold water taken at this time causes a sudden profuse 
sweat, and also relieves any overheating by abstracting many units 
of heat. The cold water in the centre of the body causes contraction 
of the bloodvessels in these parts, and the blood, rushing to the surface, 
causes the sweat glands to pour out their secretion. 

Following the stay in the warm room, the individual passes into 
still another chamber, where he is shampooed from head to foot, well 
rubbed, and the blood made to circulate through the skin. The 
shower-bath is then used, at first hot or warm, and finally changed to 
a dash of cold, or, the patient plunges into a long tank, swims to the 
other side, and is there met by an attendant who rapidly dries his skin, 
wraps a cover round him, and shows him to a lounge, where he is 
supposed to sleep for an hour or so. The air of this sleeping-room is 
at the ordinary temperature of a living-room. 

Reviewing for a moment the effects of this bath, we find that the 
first two-thirds are devoted to the opening and stimulation of the 
pores of the skin, while the last third is devoted to the contraction 
of these pores and their supplying bloodvessels. In other words, it 
is necessary to use the cold to prevent gradual chilling, which would 
result in internal congestion. If the patient receives a cold douche, 
the natural rebound prevents congestion of a permanent nature, whereas 
if he is exposed to cold a long time, these stagnated areas become per- 
manently diseased. The physician must always remember that this 



588 REMEDIAL MEASURES OTHER THAN DRUGS 

cold douche or plunge is a sine qua non, and that a rest after the bath 
before dressing is almost equally important. If the patient is too weak 
to bear the cold, he must not use the bath. 

The indications for the Turkish bath as a medicinal measure in any 
condition of the emunctories of the body whereby effete matters are 
not properly eliminated, as in Bright 's disease in its various forms. 
The increased action of the skin not only casts off impurities for the 
time being, but frequent repetition of the bath causes functional hyper- 
trophy of the sweat glands, and eventually enables them to do more 
work, or, in other words, to cast off an increased quantity of effete 
material. As a consequence of this the patient is able to decrease 
the tendency to uraemia or other evidences of Bright's disease, and, 
employing the normal epithelium still left in the kidney for constant 
use, uses the bath once, twice, or thrice a week with the object of 
abstracting the excess of impurities which the impaired kidneys cannot 
remove. The frequency of the bath depends, therefore, upon the 
rapidity with which the effete materials accumulate. In a case of 
Bright's disease the patient should not attempt to use the room con- 
taining high heat at first, and should be accompanied by a medical 
attendant to watch for untoward effects, particularly if the heart is 
diseased or uraemia is already shown by headache or other signs. If 
sweating does not come on at once, danger is at hand from acute 
uraemia, renal and cerebral congestion, or heat-stroke. 

Not only is the Turkish bath useful for kidney disease, but it is 
often of great service in rheumatism. The acute form of rheumatism 
is never so treated, because cardiac complications forbid exposure to 
heat, and fever is generally present. In subacute and chronic rheu- 
matism the case is different, and the enlarged joints or inflamed muscles 
greatly improve in some instances from such treatment. Further than 
this, the muscular stiffness following prolonged or severe effort can 
be so avoided, and neuralgia depending upon rheumatic or gouty taint 
may be relieved by the hot-air bath. 

Acute colds affecting the nasal cavities or other parts of the body, at 
an early formative stage, can often be aborted by a thorough Turkish 
bath, and when further developed are often greatly relieved by the 
same means. If, however, congestion of the lung, pneumonia, or 
chronic bronchitis, with emphysema or a dilated weak heart, is pres- 
ent, the bath may be dangerous. In acute pharyngitis, in which the 
pharynx feels like a raw surface or "as if it were filed or scraped," 
the bath will give relief in many instances. 

Sometimes in suppression of menstruation from cold the flow may 
be restored by a Turkish bath. 

Some persons complain that they are always catching cold upon 
the slightest exposure and apparently without cause. One class 
seem to have delicate mucous membranes readily susceptible to irri- 
tation and inflammation; the other have dilated or relaxed peripheral 
capillaries, which readily allow the blood in them to become chilled, 



HEAT 



589 



and the individual consequently suffers from internal local congestions. 
Two separate means of treating such cases exist. The first class will 
do well on minute doses of arsenic trioxide (grain T ^-g- to -V) three times 
a day, used for weeks; the second will be cured of their habit by the 
use of a Turkish bath twice or thrice a week, since by this means the 
peripheral capillaries are toned up and made more active. 

The Turkish bath, as thoroughly carried out in large cities, is not 
obtainable for those living elsewhere, so it is well to describe a home 
modification which, with attention to detail and care, may prove 
almost, if not quite, as effective a remedy. (See Figs. 89 and 92.) 

The patient is placed upon a wooden chair, naked, and under the 
chair a small alcohol lamp is put, which is lighted. The individual is 
now wrapped thoroughly, chair and all, with one or two large blankets, 
when the heat of the lamp soon causes profuse sweating. Many cases 
are, however, on record where the lamp has been upset and the patient 
badly burned. The best way is to have the lamp a little to one side 
and its flame immediately under the mouth of an inverted funnel 
attached to a piece of tin tubing, the free end of which is placed under 
the blanket, so that the hot air and vapor may surround the body. 
If the tube be covered with cloth, the loss of heat is slight and the 



Fig 




A method of giving a bedridden patient a hot-air bath where a sweat is desirable, or where 
shock with a collapse temperature is to be controlled. The bed-clothing is raised by a cradle. 
An alcohol lamp is placed under the inverted funnel, and the hot moist air is carried in this 
way to the patient without any danger of fire or of burning the skin by hot bottles. 



danger of burning the patient is removed. If this is not practicable, 
several very hot bricks or stones, throughly heated in an oven, may 
be placed under the chair, or small heated logs of wood may be sub- 
stituted. 

When the patient is too feeble to sit in a chair, then it is wise to 



590 



REMEDIAL MEASURES OTHER THAN DRUGS 



place an alcohol lamp at the foot of the bed, with an inverted funnel 
attached to a tube which passes under the bed-clothing in such a way 
as not to bring the hot air directly against the skin of the patient. The 
bed-clothing may be slightly raised to allow the hot air to enter. The 
vapor of the alcohol lamp tends to sweat the patient. This is also a 
valuable mode of using external heat in cases of shock (Fig. 89). 

A modified form of Turkish bath, now commonly resorted to, is the 
electric cabinet bath. This consists of a box large enough for the 
patient to sit in on a stool after he is stripped. His head projects 
through a hole in the lid and a towel is placed around his neck to keep 
the hot air in the cabinet from escaping. The box being lined with 20 
to 30 incandescent lamps when the electric current is turned on they 



Fig. 90. 





1 




!■ 










, ^ 


^^ 








:"• ..';•- ' ~ ; 


1 






1 




>£>*; -;.;■■; 










: 

■ 





Electric light bath cabinet. (Jefferson Hospital, Philadelphia.) 

give off a great amount of heat so that within a few moments the tem- 
perature in the cabinet is 120° F. By reason of the stimulating effect 
of the light upon the skin the patient sweats as freely at 120° F. as he 
would in a Turkish bath at 130°, and therefore is not exposed to very 
high oppressive heat. Furthermore his head is not heated, but kept 
cool by cloths wrung out in ice-water, and, as he does not inhale hot air, 
his lungs are not exposed to great change of temperature when he goes 
out of doors. This he should not do, however, in any event before one 



HEAT 



591 



or two hours. After being in the cabinet fifteen to twenty minutes he 
is found to be sweating freely. He is then allowed to get out, is rubbed 
down with tepid water and soap, and finally with alcohol and water, 
and after this should lie down lightly covered and cool off gradually. 
Although he should be dried with a towel he should not be rubbed 
with it, as this again dilates the skin vessels and induces further sweat- 
ing. When an electric cabinet is not obtainable, a folding frame 
covered with rubber sheeting may be obtained from any instrument 
maker and the heat supplied by an alcohol or other lamp or a Bunsen 
burner. A similar apparatus shaped so that it covers the patient 
when lying in bed can also be had for patients too weak to sit up. 

Fig. 91. 




JNurses using two broom-sticks to wring out a blanket dipped in very hot water for use 
in the hot pack. (From the author's wards.) 

The Russian bath differs from the Turkish in that the heat used is 
moist, not dry. As a consequence the danger of heat-stroke and similar 
states is much increased, because evaporation from the skin does not 
go on so rapidly and the body is not cooled so well. 

The hot moist bath can also be obtained by seating the patient on 
a wicker chair under which is placed a bucket of hot water. The 
patient is surrounded by a blanket, and a large hot iron or stone is 



592 



REMEDIAL MEASURES OTHER THAN DRUGS 



put into the water, causing the development of a great amount of 
steam. 

This method of treatment is useful in the same states as is the 
Turkish bath, but is more rarely used. It may also be employed to 
develop the rash of any of the exanthematous fevers when it is sup- 
pressed by cold or is not "well out" on the skin. 

Under the name of the "hot pack" still another substitute for the 
Turkish or Russian bath is used, not only to cause sweating and so 
relieve the patient of poisons in renal diseases, but also to relax muscle 
spasm and to relieve nervous excitement and nervous insomida. It is 
particularly efficacious in the insomnia of severe chorea in children, and 
may be used in tetanus. 

A bed is prepared by covering it with a rubber blanket. Over this 
is placed a dry woollen blanket. A large heavy blanket is now dipped 
in very hot water and then wrung out (Fig. 91), and the naked 
patient quickly wrapped in it, the dry blanket being folded over him 
after several hot-water bottles have been placed alongside the patient. 
Finally the sides of the rubber sheet are drawn around and over the 
patient and an ice-cap placed on the head (Fig. 92). A thermometer 
should be placed in the mouth every fifteen minutes, and if the patient's 
temperature becomes febrile (101° F.) he should be taken out of the 
blankets and rubbed dry. Ordinarily the bath should last about one 
hour, and if sweating does not speedily come on a glass of cold water 
should be taken to drive the blood to the skin. In adults a little gin 

Fig. 92. 




Showing arrangement of blankets in giving a hot pack for uraemia. (From the author's wards.) 



may be added to it, or sweet spirit of nitre may be used in this way in 
children and adults. If no sweat develops and the temperature begins 
to rise, the patient must be taken out of the bath at once. The hot 
pack in uraemia is contraindicated if there is any tendency to pul- 
monary oedema. 

The mustard hot pack is often useful in the treatment of internal 
congestions and particularly so in the bronchopneumonia of infants 
and children. It is to be employed as follows: 



HEAT 



593 



Oil of mustard, 10 minims (0.65), is thoroughly mixed with a pint 
(500 mils.) of alcohol and water in equal parts, the water being heated 
before the mixture is made. A large piece of flannel is saturated with 
this mixture and the child is wrapped in it from the neck to the feet, 
and then, in turn, wrapped in a thin blanket. After the lapse of ten to 
twenty minutes the skin will be found to be bright red, and the flannel 
is then taken off and the child wrapped in another piece of flannel 
which has been wrung out in a mixture of alcohol and warm water 
in the proportion of one to two parts. In this second wrapping the 
child lies for half an hour, after which it is again wrapped in a dry 
blanket or, if the weather is warm, in a dry sheet. The mild counter- 
irritant effect of this application draws the blood from the congested 
lungs, and in the case of eruptive fevers, in which the eruption is not 



Fig. 93. 




Frazier-Lentz hot-air apparatus. 

fully developed, it will frequently relieve nervous symptoms and develop 
a rash. If there is reason to believe that the child's skin is exceedingly 
sensitive, 5 minims (0.033) of the oil of mustard instead of 10 minims 
(0.65) should be employed. 

Another wet pack, which speedily becomes a warm one, is used in 
cases in which, during the course of an eruptive fever, the eruption fades 
and it is desired to bring it out on the surface. It is also useful in those 
cases of severe chorea in which the child can withstand the first shock 
of the cold. It consists in wrapping the child in a cool wet sheet 
and over this wrapping one or two blankets. In a few minutes the 
sheet becomes heated by the body and the sweating which results is 
profuse. 
38 



594 



REMEDIAL MEASURES OTHER THAN DRUGS 



Whenever the Turkish or Russian bath or hot pack is used, except 
in the exanthematous fevers, it should be followed by a cool sponge, 
plunge, or douche. 

Although these baths have been used in the treatment of cases of 
heart disease to relieve dropsy and renal engorgement, they are not 
safe, and should not be generally employed. All acute or chronic 
diseases of the lung, except acute bronchitis of a mild form, contra- 
indicate their use. 

A valuable method for using moist heat in a mild form is the "bron- 
chitis tent." (See article on Bronchitis.) 

The use of a high degree of dry heat for the cure of inflammatory 
states of the sheaths of the joints and muscles has recently been made 
once more popular by the introduction of a double copper cylinder 
closed at one end, inside of which is placed the limb which is affected. 
The limb is prevented from coming in content with the cylinder by 
means of a board padded with asbestos and by putting pads of linen 
under the parts which touch the asbestos. A thermometer is placed 
so that its bulb extends into the cylinder, and a few holes permit of 
the moderate circulation of air. Bunsen burners or alcohol lamps are 
now lighted and placed under the cylinder, and the orifice through 
which the limb enters it is closed by drawing around the limb an 
asbestos curtain. The temperature is allowed to rise to 200° to 300° F., 
and the treatment resorted to daily, or several times a week, the indi- 
vidual seance lasting about one hour. The free sweating of the limb 



Fig. 94. 




The Newell hot-air apparatus. 



and the circulation of the blood and lymph prevent it from being burnt, 
but care must be taken that it does not touch the metal. Usually the 
entire surface of the body sweats profusely during the sitting. 



HYPODERMOCLYSIS 



595 



The author believes this method to be of great value in cases of 
chronic inflammatory joint affections due to rheumatism or following 
injuries, but of little service in those due to gouty swelling. In sub- 
acute gout he has seen it precipitate an attack of universal acute gout, 
apparently by setting free large amounts of urates from the affected 
joints. 

^ This method of treatment is always to be considered as a valuable 
aid in the treatment of the more obstinate cases of the character 
described. The best form of this apparatus is expensive. A less 
expensive apparatus is shown in Fig. 94. 

HYPODERMOCLYSIS. 

Hypodermoclysis is a method of supplying fluid to the body to replace 
that lost through excessive purging, as in cholera, or in cases of hemor- 
rhage. Further, it may be used to wash from the body various impuri- 
ties circulating in the blood and lymph, and to flush the kidneys. In 
other instances it may. be used to supply the body with liquid when 
the stomach will not permit liquid to be swallowed, as in vomiting, or 
gastric ulcer or after abdominal operations. It consists in the intro- 
duction into the subcutaneous tissues of normal saline solution, w T hich 



g. 95. 




The apparatus and method used in giving hypodermoclysis. The ordinary irrigator is attached 
to a small canula, and this is placed in the loose tissues of the belly-wall. 



is rapidly absorbed by the vessels. As is well known, a quantity of 
liquid equal to four times that of the normal amount of blood may 
be passed directly into the veins without producing a rise of blood- 
pressure, and experiment has shown that usually within fifteen minutes 



596 REMEDIAL MEASURES OTHER THAN DRUGS 

after the fluid flows into the subcutaneous tissues an increased flow 
from the kidneys takes place. It is not safe to infuse a greater quantity 
of liquid than 1 drachm to each pound of body-weight in each fifteen 
minutes, as, if this amount is exceeded, the accumulation of the liquid 
in the system is so great that the tissues become drowned, because the 
kidneys cannot excrete the liquid fast enough. To carry out the opera- 
tion, the sterilized liquid to be infused— the formula on page 621 is the 
best— is placed in a glass irrigator jar or rubber bag, which is abso- 
lutely septic. From the lower part of the vessel leads a rubber tube 
to which is attached a large hollow needle, also rendered sterile. The 
skin over the place where the liquid is to enter is to be rendered abso- 
lutely sterile, the needle is then inserted into the subcutaneous tissue 
of the thigh, or, preferably, of the abdomen, or below the breast, 
and the liquid allowed to flow at a rate named, the pressure being 
obtained by raising the container two feet above the belly-wall (Fig. 
95). As the liquid enters, a swelling appears in the subcutaneous 
tissues, which soon disappears after the infusion ceases, and is 
much aided in its absorption by the use of very gentle rubbing or 
stroking. 

When hypodermoclysis is employed after hemorrhage, the results 
are often extraordinary. It is of great value in the collapse of cholera. 
(See Cholera.) The cyanosis decreases rapidly, the pulse improves, 
and respiration is no longer difficult. Some physicians have used hypo- 
dermoclysis with very good results in the treatment of uraemia due to 
chronic contracted kidney after venesection, thereby diluting the 
poisons and preventing them from acting so severely. In septicaemia, 
diabetic coma, and similar states this method of treatment may be 
employed. When general dropsy is present, it is manifestly useless 
and harmful. Hypodermoclysis has also been used with great ad- 
vantage in the treatment of severe burns to overcome shock and 
toxaemia. 

In cases of surgical sJiock warm saline fluid used by hypodermo- 
clysis is often of great service. (See also Intravenous Injection; 
Transfusion.) 

INHALATIONS. 

The value of inhalations is not recognized sufficiently by the medical 
profession. As a matter of fact, they are capable of aiding vety 
much in the treatment of disease and of producing results otherwise 
unobtainable. The employment of inhalations may be divided into 
the properly modified use of atmospheric air and the employment of 
atmospheric air charged with medicinal substances. To carry on many 
of the forms of treatment which have been found of value requires 
cumbersome or costly apparatus which cannot be used except in insti- 
tutions; but nevertheless the general practitioner can employ remedial 
measures by way of the respiratory organs with great advantage to 



INHALATIONS 597 

his patients even when far removed from places where costly apparatus 
can be had. 

The first form of inhalation to be studied is that which is devoted 
to proper respiratory exercises. These exercises are required by 
patients who because of faulty development do not properly expand 
certain portions of the chest in the function of respiration, and by those 
who have acquired impaired respiratory movements through the 
following of certain occupations or as the result of attacks of disease. 

There can be no doubt that pulmonary tuberculosis may be pre- 
vented, or even arrested in its earliest stages, by causing a patient to 
use proper thoracic exercises, which must usually be directed toward 
producing expansion of the apices of the lungs, a part of these organs 
which in many instances is but poorly filled and equally ineffectively 
emptied under ordinary conditions of life. The following inhalation 
exercises are to be directed for such cases: 

The patient stands with his back against a wall, holding himself 
as erect as possible and bringing his shoulder-blades flat against the 
plane behind him. He now takes a slow, deep, and full inspiration, 
drawing the air into the chest in a steady stream, and not by a sudden 
jerk of the respiratory muscles. The inspired air is to be held in 
the chest while the patient mentally counts three, and then allowed 
to escape gradually, and not forced out of the chest by sudden mus- 
cular effort. Usually four or five such movements night and morning 
are quite sufficient for good results for the first w T eek. After that time 
they may be gradually increased in number. 

Another movement may now be added to that just described. The 
patient, standing with his back against the wall and the shoulders 
well thrown back, raises his arms, which are completely extended 
from the sides until the hands are on a level with the shoulders, thereby 
fully expanding the sides of the chest. As expiration begins the arms 
are allowed to fall gradually to the sides. After this the arms may be 
carried above the head into a perpendicular position. 

A third exercise consists in inhaling as deeply as possible and then 
exhaling against resistance produced by closing the lips and forcing 
the air between them. 

The fourth exercise consists in lying upon a firm bed with a small 
pillow under the hollow of the back and no pillow under the head, and 
then taking slow, long-drawn inspirations and expirations as already 
described. 

These exercises are useful not only in persons with faulty chest 
development, but also in those who have poor expansion of a lung 
after a pneumonia, pleurisy, or empyema. 

The increase in the volume of air respired under gentle but per- 
sistently taken exercise of this character is quite remarkable and these 
movements often increase the appetite, the proportion of haemoglobin, 
and the general health of the patient. 

In addition to these exercises there are others which, while not 



598 



REMEDIAL MEASURES OTHER THAN DRUGS 



directly connected with breathing produce, nevertheless, deeper respira- 
tions and at the same time develop the chest muscles and cause the 
patient to hold himself erect, thereby preventing or correcting faulty 
pulmonary expansion. Nearly every physician can look back upon 
cases in which a slovenly carriage of the shoulders in early life has 
resulted in impaired chest expansion and finally in actual disease. 
The exercises to be ordered are shown in Figs. 96 to 103. 



Fig. 98. 



Fig. 97. 




Standing erect. 
Fig. 98. 





Stretch standing. 

Fig. 99. 




Wing stanuing, side bending. 



Wing standing, trunk rotation.. 



INHALATIONS 



599 



Fig. 100. 



X.'.-il 




Fig. 101. 

fism 




Wing standing, knee bending Stride standing, forward bending, or hewing, 

or curtseying. 



Fig. 102. 



Fig. 103. 





Half wing, half stretch, standing; 
forward bending, or sawing. 



Wing standing, leg circling. 



The next class of exercises consist in using simple forms of apparatus 
in association with respiratory movements. These are advantageous 
not only because they are beneficial in themselves, but also because 
they interest the patient and cause him to take exercises of which he 
might tire if they were performed without appliances. 

The first of these consists in a pair of Wolff bottles joined together 
by a piece of rubber tubing (Fig. 104) . The bottle nearest the patient 



600 



REMEDIAL MEASURES OTHER THAN DRUGS 



is filled with water, and the patient, after taking a deep inspiration at 
the moment of expiration, places a mouth-piece attached to a rubber 
tube between his lips and forces the water over from the first to the 
second bottle. This is usually sufficient for an exercise, and later in 
the day the patient drives the fluid from one bottle to the other a 
second time. Such a procedure causes the patient to take full inspira- 
tions and forcible, though gradual, expirations, with the result that he 



Fig. 104. 




Arrangement of bottles for promoting lung expansion. 

fully expands portions of the lungs hitherto but imperfectly inflated. 
It is therefore of value in patients with poorly developed chests, in 
cases after an attack of pneumonia, when complete resolution is long 
delayed, and in instances of deficient pulmonary expansion because of 

Fio. 105. 




Denison's resistance inhaler. When in use the cap at the end of the inhaler is removed and 
air is drawn into the square chamber, which contains a piece of folded absorbent paper or cotton 
wet with some of the volatile oils named in the text. The air then passes to the patient by way 
of the mouth-piece, meeting, however, a resistance valve on the way designed to produce forced 
inhalations. On expiration the air goes through the mouth-piece as far as the perforated elevated 
column, where, by a valve, it escapes. By means of the cap on top of this column the resistance 
offered by the valve to the escape of the air is increased or diminished as is desired, so that the 
patient expires against resistance. 



adhesions following an attack of pleurisy. In cases of empyema after 
drainage is established it is useful in that it aids drainage, keeps the 



INHALATIONS 



601 



pleural cavity free from pus, and gradually causes the lung to descend 
once more into the lower part of the thorax. This practice is a very 
useful one in children, who may otherwise suffer from deformity due to 
collapse of one side of the chest if the lung is not properly expanded. 
It is not to be practiced immediately after the removal of a pleural 
effusion or empyema, because time must be given the lung to expand 
naturally and adjust itself to the relief of pressure. It must be used 
with caution in pulmonary tuberculosis because forcible expiratory 
strain may induce pneumothorax. 

Another form of apparatus, designed for the same purpose as that 
just named, is > "Denison's Resistance Inhaler." (See Fig. 105.) The 
physician having determined that the patient is to inhale air against 
resistance, the valve is fixed to yield to a pressure caused by his forcible 
inspiration. On the other hand, when the patient exhales the muscles 
of the chest must use sufficient pressure to force the air past the expira- 
tion valve. The result is that every part of the lung is expanded, the 
respiratory muscles are exercised and strengthened, and what might 
be called slovenly or imperfect breathing is corrected. 

Fig. 106. 




Chamber inhaler (Hassall). The shelves are made of cotton cloth, upon which is poured 
the medicine to be employed. 

We now pass to the consideration of inhalations designed to carry 
medicinal substances into the lungs for their effect on the respiratory 
tract or to influence the general system, not including, however, the 
use of general anaesthetics. The air respired may be medicated by 
the following methods: (1) Setting free in the air of the room 
volatile substances derived from chemical or vegetable sources, using 
materials which are naturally volatile or which can be made so by 
the aid of dry or moist heat. (2) The use of a mask or inhaler so 
arranged that a part at least of the inspired air must pass through 
or over a sponge or piece of cotton moistened with the medicament. 



602 



REMEDIAL MEASURES OTHER THAN DRUGS 



(3) The nebulizing of substances which are not volatile, by the use of 
compressed air. 

The use of chloride of ammonium fumes in cases of chronic bron- 
chitis is described in the article on Ammonium Chloride. In cases 
of spasmodic croup a few crystals of menthol placed in an iron spoon 
may be volatilized over a gas jet or lamp chimney, and so diffuse the 
vapor through the air. (See Croup.) 

Creosote is said to produce very good effects in vihooping-cough, 
and in bronchitis in its later stages, if cloths wet with it are hung about 
the room. So, too, turpentine, terebene, eucalyptol, and similar 
substances can be used in place of creosote, and in doing so the 
apparatus for diffusing these drugs in the air described by Hassall 
may be employed (Fig. 106). 

In other instances it is better to set free these and other substances 
by the aid of steam, allowing the steam to escape freely into the air of 

Fig. 107. 




Croup kettle and inhaler. 

the room or to enter a "bronchitis tent." (See article on Bronchitis.) 
5 to 20 minims (0.3-1.3) of any of the substances just named may be 
added to the water when it is boiling. Menthol may also be so used, 
placing 2 to 5 grains (0.12-0.3) in the hot water at a time. The steam 
allays irritation by increasing the moisture in the air of the room, checks 
coughing, and aids the action of the drugs. Steam usually does badly, 
however, if there is an excess of secretion in the lungs. The drug to be 



INHALATIONS. 



603 



used may be placed in the water in an ordinary teapot heated by a lamp, 
or gas jet, or the "croup kettle" may be employed (Fig. 107), or in 
its place the appliance shown in the article on Bronchitis (Fig. 102). 
In other instances the apparatus shown in Fig. 108 may be used. In 
this arrangement the medicated steam is generated in the boiler and 
then escapes from the upper end of the tube and is inhaled by the 
patient, who brings his face as near to the apparatus as the heat will 
permit. 

Fig. 108. 




Steam vaporizer. 

The following formula is useful in many cases of pulmonary tuber- 
culosis and bronchitis with a dry cough, if placed in such a steam 
inhaler : 

3— Olei pini sylvestris fgj (30.0). 

Olei eucalypti f§j (30.0). 

Creosoti . fgss (16.0).— M. 

S. — Place 1 to 3 drachms (4.0-12.0) in the water in the boiler and inhale the steam 
three or four times a day. 

If there is excessive cough, \ ounce (15.0) of spirit of chloroform 
may be added to the above prescription with advantage. 

In many cases of acute laryngitis the following formula is of excellent 
service if used in this manner : 






604 



REMEDIAL MEASURES OTHER THAN DRUGS 



ty — Tincturas benzoini compositi .... foj(30.0). 

Mentholis gr . x (0.60). 

Spiritus chloroformi f §ss (16.0). M. 

^ S.— Place 1 to 2 drachms (4.0-8.0) in the water in the boiler, inhaling the steam 
irom a ireshly made watery mixture several times a day. 

After using the steam inhalations the patient must not inhale for 
several hours the outdoor air if it is cold. 

Fig. 109. 




Yeo's inhaler, made of perforated zinc bound on the edges with chamois skin and supplied with 
elastic loops to go back of the ears or around the head. On a sponge placed in the front of the 
inhaler is dropped the medicine to be inhaled. 

Fig. 110. 




Evans' pocket inhaler. Half size. The finger of the patient may be placed over the opening 
marked 1 when exhaling, and over that marked 2 when inhaling. 

For use with the mask or face inhaler (Fig. 109) or Denison's inhaler 
(Fig. 105) the following formula is valuable in cases of chronic bronchitis 
with excessive cough : 

3— Chloroformi f g ss (16.0). 

Creosoti f § ss (16.0). 

Mentholis . .• gr. x (0.60).— M. 

S. — 10 drops on the inhaler every three hours. 



INHALATIONS. 605 

Any one of these ingredients may be used alone. Sometimes where 
it is desired to liquefy tenacious bronchial mucus 10 drops of iodide of 
ethyl may also be placed on the inhaler to act as a stimulant expec- 
torant. The mask or Yeo inhaler must be used almost constantly if 
it is to produce good results. 

Small pocket inhalers containing medicated cotton may be used. 
A small glass tube is partly filled with cotton, and this is kept in place 
by perforated corks fixed in either end. Any of the medicaments 
named may be placed on this cotton, and the air inhaled through the 
tube. A tube of this sort packed with crystals of menthol, and called 
a "Menthol Inhaler," is largely sold at present. It is of value in acute 
colds. A useful modification of this straight tube is that of Evans 
(Fig. 110). In this apparatus the sponge in the bulb is wet with the 
medicament. 

There are on the market at the present time a large number of 
so-called vaporizers or nebulizers, which by the aid of compressed air 
force the medicament to be inhaled in a fine spray against the side 
of the glass containing it, in this manner still further comminuting it 
and causing it to escape from the bottle or bulb as an exceedingly 
fine vapor. The larger ones are supplied, as a rule, with compressed 

Fig. 111. 




Glaseptic nebulizer. 

air from a force pump or large hand pump. The smaller ones are 
worked by a small hand pump or rubber bulb. The forms employed 
largely by the writer are those of Robertson and the Glaseptic. (See 
Fig. 111.) For a satisfactory use of these nebulizers the medica- 
ment had better be dissolved in an oily fluid. The following formula 
may be used in such apparatus in coryza or acute inflammation of the 
upper respiratory tract. 

~fy— Mentholis gr. xx (1.3). 

Camphorse . gr. x (0.6). 

Alboleni (liquid) fgj (30.0).— M. 

S. — Plate in the nebulizer and inhale the vapor several times a day. 

A somewhat similar formula of even greater value than this con- 
tains, in addition to the above, 2 to 5 grains (0.12-0.3) of chloretone, 



606 REMEDIAL MEASURES OTHER THAN DRUGS. 

which is useful in that it is anaesthetic and sedative to the mucous 
membranes. (See article on Peppermint.) Where the inflammation 
is very severe and acute, it is often well to substitute for the above 
formula the following one : 

1$ — Olei sassafras ... . gr. iij (0.2). 

Olei santali n\,v (0.3). 

Alboleni (liquid) f §j (30.0).— M. 

S.- -Use in voporizer. 

In such small amounts sandal-wood oil is sedative. If we wish to 
use it as a stimulant expectorant, the quantity may be increased to 30 
minims (2.0). An even more stimulant inhalation in cases of chronic 
bronchitis is as follows: 

3— Olei eucalypti . ■ . f 3j (4.0). 

Olei picis liquidae ....„., £ 3 i j (8.0). 

Alboleni (liquid) . . . . . . . fgj (30.0).— M. 

S. — Use in nebulizer. 



INTRAVENOUS INJECTION. 

Various formulae exist for the preparation of the so-called normal 
saline solution. Some persons are content to employ a solution of 
common salt in the strength of If drachms (0.7 per cent.) to the quart 
in distilled or sterilized water, but this is a dangerous practice for the 
following reasons: 

Very slight variations in the percentage of normal saline solution 
render it harmful. While the 0.7 to 0.9 may be considered per- 
missible, a solution lower than 0.6 should not be used, because of the 
deleterious effects on the red blood cells and also because it will abstract 
salts from the tissues. If the solution is too strong it will cause the 
cells to part with their fluid. 

It is evident, therefore, that an absolutely correct percentage is 
essential if salt solutions are to be employed. Many years ago Dr. 
Sydney Ringer, in London, found by accident, and proved by careful 
experiment, that a small quantity of calcium was essential to the satis- 
factory use of a sodium chloride solution. Later than this Loeb, 
Howell, Locke, and others have shown, with Ringer, that calcium 
and potassium are both essential, and Howell has concluded that the 
sodium maintains the proper osmotic relations between the cells and 
the fluid, that the calcium is a stimulating agent to the heart muscle, 
and that potassium is essential to its rhythmical contraction and 
relaxation. 

Surgeons and physicians should not be content to employ salt 
solution prepared by haphazard methods. It is vitally important 
that these solutions shall be most accurately prepared, not only 
because they will fail to be of benefit if they are carelessly used, but 
also because the physician may do actual damage and impair his 
patient's chances of recovery if such care is not followed. 



INTRAVENOUS INJECTION. 607 

In addition to the effects which may be exercised upon the blood 
and its serum, it is interesting to note that Brown has shown that the 
use of pure sodium chloride solutions is not infrequently followed by 
glycosuria, whereas if calcium is added to the solution such a leakage 
of sugar does not take place. The old rule, therefore, that the normal 
salt solution may be made by adding a teaspoonful of common salt 
to a pint of water ought never to be followed if it can be avoided. 
Mathews also believes, and I heartily agree with him, that when 
large quantities of fluid are used in the peritoneal cavity, calcium and 
potassium should beipresent in addition to sodium chloride in normal 
quantities. 

The best solution, because it at once supplants the blood which has 
been lost or is impure, and because it supports the heart, is: 

Calcium chloride 0.25 

Potassium chloride , 0.1 

Sodium chloride . 9.0 

Sterilized water 1000 mils. 

At the author's suggestion, these sterilized salts are now placed upon 
the market in hermetically sealed glass tubes. The contents of one of 
these vials added to 1 quart (1000 mils.) of pure sterile water make a 
normal saline fluid ready for instant use. 

Recent researches have shown that many of the untoward effects 
which follow injection are due, not to the entrance of the fluid, 
but to the fact that the water, even if sterilized by boiling, contains 
the toxic products of bacteria or fungi which are primarily present in 
the water. The water should therefore be distilled instead of boiled 
and used as soon after distillation as possible. 

The apparatus and technique used are as follows: 

1. A sterile pitcher, in which is placed the hot salt solution with a 
sterile thermometer immersed in it so that temperature of 110° F. 
may be shown to be present. 

2. A flask such as is used for giving salvarsan. (See Fig. 112.) 

3. Rubber tubing, at the distal end of which is a nozzle to fit in 
the needle used to enter the vein. In this rubber tube a segment of 
glass tubing or an infusion thermometer should be inserted in order 
that air globules may be discovered and the temperature of the flowing 
fluid watched. The tubing should, of course, be sterile and long 
enough to permit it to be coiled in (4) a basin of hot water so that the 
salt solution as it passes slowly through the tubing to the vein 
does not become chilled. 

5. The skin over the vein, usually one of the arm, is sterilized by 
iodine tincture and washed off by alcohol. 

6. The reservoir is now held so that the tube hangs perpendicularly 
and fluid is poured from the pitcher to displace air from the tube. 
When air-free a clip is placed on the distal end of the tube near the 
nozzle to hold the fluid in and keep the air out if the distal end of 
the tube is lifted. 



608 



REMEDIAL MEASURES OTHER THAN DRUGS. 



7. The needle is now inserted in the vein and as soon as this is 
done the clip is released and, as the solution escapes, the nozzle is 
inserted in the shank of the needle. 

8. The reservoir is held about 1 foot above the arm and at least 
thirty minutes should be used in injecting as much as 1 quart. 

9. If the arm is fat, or the vein collapsed, it may be necessary to 
incise the skin and expose the vessel. 

10. In infants saline solution, or dextrose in 5 per cent, solution (3 
grains to each pound of patient), may be injected into the longitudinal 
sinus through the posterior portion of the fontanelle in the middle 
line. Four to eight ounces (120.0-240.0) is usually enough. (See 
Transfusion.) 

Fig. 112. 




The reservoir, tube and needle of this apparatus may be used for intravenous injection. 



As the injection is given the pulse begins to improve, the respira- 
tions are deeper and less hurried, and if fever is present the tempera- 
ture usually falls. The patient is evidently better, but soon enters a 
critical stage, particularly if the water has not been properly pre- 
pared, which may come on in from two to thirty minutes. There are 
sometimes a violent chill, a strong, rapid pulse, and in the course of 
three-quarters of an hour a flushing of the skin, followed by profuse 
sweat. The respiration may be labored. The urinary flow is also 
increased, and sometimes water escapes from the bowel. These 
symptoms rarely occur if freshly distilled water is used. Several 



INTRAVENOUS INJECTION. 



609 



hours later the real benefit appears in convalescence or in marked 
improvement. 

It is important to bear in mind that a very low content of hemo- 
globin is compatible with life if only the bulk of the blood is restored. 

Saline injections may be given to compensate for acute hemorrhage, 
to diminish toxemia (see Diabetes), and to give the body fluid when 
it has been deprived of it by profuse vomiting and purging, (See 
Cholera.) Unless the conditions are urgent hypodermoclysis or proc- 
toclysis may be sufficient in such cases. (See Hypodermoclysis and 
article on Peritonitis.) The amount of saline given intravenously 
usually varies from a pint to a quart. 





Chart I. 


Fig. 113. 


Chart II. 






HOURS 2 3 4 5 6 


2 


3 4 5 6 7 


(A 
m 

UJ 

or 
a. 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 
















































I 























h 






























4 






















1 














\ 








l7 






















1 










i 












I 














V 


/\ 


\ 


/ 












1 








\ 


/ 












i 










/ 


































No: 


EFFECT OF NORMAL 
SALINE. 


No. 


2 EFFECT OF' ACACIA- 
NORMAL SALINE. 



I. Temporary rise of blood-pressure from normal saline. II. Maintained 
rise from acacia solution. 



When diabetic coma (see Diabetes) exists the benefit is often only 
temporary. 

In uremia and in puerperal convulsions the patient should be bled 
before, or simultaneously with, the injection, if the arterial tension is 
high or the veins turgid. 

In the treatment of Asiatic cholera it has been found advantageous 
to use a salt solution of 1.0 per cent. (See Cholera, Part IV.) 
If there is a tendency to pulmonary oedema or general anasarca in- 
jections are contraindicated. 

A saline solution is used intravenously by some persons to combat 
shock. Experience has shown that it is useless for this purpose because 
39 



610 REMEDIAL MEASURES OTHER THAN DRUGS. 

the dilated vascular system is not constricted by its use and a pint or 
quart of fluid does not increase the bulk of blood where it is needed, if 
at all, because the vessels relax still more and the fluid transudes into 
the tissues. (See Shock, Part IV.) Any temporary gain is due to 
the heat in the solution. This temporary effect on blood-pressure is 
shown in Chart I. Only whole blood from a proper donor does 
good (see Transfusion), or a saline solution of such hypertonicity 
that it takes fluid from the tissues, instead of pouring it out into 
them, is of any value. (See below and article on Cholera for Hyper- 
tonic solutions.) 

Bayliss and others have advised the employment of gum acacia in 
the strength of 20 grams to each 1000 mils, of normal saline, or in a 
hypertonic solution made by doubling the amount of sodium chloride 
and of the calcium chloride, but not the potassium. They believe that 
the viscosity of this fluid renders it capable of maintaining blood- 
pressure better than normal saline because it does not transude and 
also because it is not so quickly lost through the kidneys. Acacia 
has the advantage over gelatin of being easily sterilized and, as it 
contains no protein, there is no danger of anaphylaxis. The effect 
of such a fluid on blood-pressure is diagrammatically shown in Chart II. 

The intravenous injection of medicines is a method which is to be 
employed only under extraordinary circumstances and with only a 
few drugs, as, for example, salvarsan in syphilis and quinine in severe 
malarial infection. (See Salvarsan and Cinchona.) The injection 
should be made very slowly, and the drug should be, as a rule, well 
diluted so that it will not reach the heart in a concentrated form, 
temporary cardiac depression being thereby avoided. 

The objections to intravenous injections are several. In the first 
place, the veins are apt to be collapsed and hard to find, and it is 
difficult to puncture one without wounding the opposite wall of the 
vessel. Again, phlebitis is a possible sequel, and thrombosis and 
embolism are by no means impossible. 

It is needless to say that the solution of the drug which is injected 
into a vein should always be nearly neutral or alkaline in reaction in 
order to avoid coagulation of the blood. 

LAVAGE. 

This is a term applied to washing out of the stomach in cases of 
gastric dilatation, chronic gastritis, and more rarely in cases of gastric 
carcinoma. It is particularly valuable in the two first-named condi- 
tions not merely for its curative power, but also to rid the stomach of 
mucus and render it clean before fresh food is ingested. 

The liquid employed should always be warmed. For an adult 
a tube should be used of at least four and a half to five feet in length, 
of which eighteen inches pass into the mouth, the remaining portion 
reaching to the basin when lowered to allow siphonage. The ques- 



LAVAGE. 



611 



tion as to the variety of tube to be employed is a vital one, since a 
poorly devised apparatus not only gives no relief, but disgusts both 
the patient and the physician with the technique of the method. The 
tube should be more like a hollow bougie than a catheter, in order 
that its calibre may be great enough to carry off some of the semi- 
solid materials present. If this rule is not followed, two evil results 
follow: In the first place, the tube and its apertures rapidly, or even 

Fig. 114. 




The stomach-tube having been passed, the funnel is filled from a pitcher and elevated to 
urge the water into the viscus. 

at once, become clogged; secondly, the liquid is drained away leav- 
ing behind a mass which is semisolid, to be sure, and less bulky, but 
which is nevertheless the quintessence of the nastiness of fermentation, 
and quite as qualified to contaminate any fresh food on its entrance 
as the liquid would be. 

The holes in the gastric end of the tube should therefore be of suffi- 



612 



REMEDIAL MEASURES OTHER THAN DRUGS. 



cient size to take in fairly large masses. In most cases the ordinary 
siphon may be used, but where there is any solid food or resistance 
suction by means of a stomach-pump is necessary. 

The best tube for adults is No. 20, made of red Para rubber with 
lateral holes. 

The methods by which lavage is employed, in addition to those which 
have been named, are as follows: The tube should be passed back- 
ward against the roof of the mouth, so that by following the curve 

Fig. 115. 




Just as the last portion of the water is about to disappear down the tube the funnel end is lowered and 
the contents of the stomach are siphoned out. 



of the hard and soft palates it is directed into the pharynx and 
oesophagus, and then by gentle pressure forced into the stomach. At 
the same time the patient should be directed to swallow. The mucus 
in the throat sufficiently lubricates the tube, and oil is not to be used. 
If gagging is excessive, the pharynx may be first painted with cocaine. 
The irritability of the pharynx usually rapidly disappears, and it is 
surprising how quickly the patient becomes accustomed to the opera- 
tion, and submits to it without any feeling of discomfort. After the 
tube has reached the stomach a small funnel is to be fitted in its exter- 



LEECHING. 613 

nal end, which is then held above the head of the patient while water 
prepared in the way already mentioned is poured into it until the 
stomach is filled, when the funnel end is lowered and the stomach is 
emptied by siphonage. 

The stomach-pump has one very serious disadvantage, which is 
present with even more force in the case of a child than in an adult— 
namely, the danger of injury to the coats of the organ. This appa- 
ratus is also more costly and cumbersome, and for children the siphon 
is powerful enough in its action to take away all excuse for the use of 
the more complicated apparatus unless the contents of the stomach 
are in bulk. 

It is particularly necessary in children, if a catheter is used and 
on account of the lack of intelligent aid and their liability to gulp, 
that every care should be taken that the tube does not slip entirely 
out of reach into the stomach; and for the prevention of this danger 
a string should be attached to the eternal end of the catheter before 
it is introduced, and the tube should always be at least thirty inches 
in length. 

LEECHING. 

Leeching is a method of abstracting blood for the purpose of reliev- 
ing local inflammations or acute congestions. There are two forms 
of leech commonly employed in medicine, both of which are imported. 
A small leech is found in many streams in the United States. Leeches, 
after attaching themselves to the skin by means of their sucking appa- 
ratus and teeth, secrete a liquid which prevents coagulation of blood, 
and this accounts for the persistent hemorrhage sometimes seen after 
a leech-bite. 

Fig. 110 




Showing the application of leeches in front of and behind the ear, for the relief of the early stages of 
acute otitis. The auditory meatus is plugged with cotton to prevent the leech from entering the canal 
by accident. 

Therapeutics. — The reasons for using venesection or depletion are 
considered farther on, and we can therefore pass directly to the uses 
to which leeches are put. In cases of meningitis they may be applied 
to the temples or to the nape of the neck, and they are useful in the 



614 



REMEDIAL MEASURES OTHER THAN DRUGS. 



treatment of swollen joints, such as occur after sprains. In orchitis 
they should not be placed upon the scrotum, but on the groin. In con- 
junctivitis or inflammation of the eye they should be applied upon the 
temple or back of the ears, not upon the lid itself. The effect of leech- 
ing is not only that of depletion, but also one of counterirritation. 

Richaud's table indicating the areas of the skin to which leeches or cups are to be 
applied to directly affect the viscera by abstraction of blood. 



Areas to be Depleted. 

Appendix. 

Liver. 

Uterus. 

Bladder and prostate. 

Testicle. 

Pericardium. 

Lung. 

Eye. 



Areas to which Depletion is 
to be Applied. 

Groin. 



Anus. 



Anus. 



Anus. 



Groin. 



Tonsil. 



Third, fourth, and fifth left 
intercostal spaces. 

Third right intercostal 
space between the verte- 
bral column and shoulder- 
blade. 

Mastoid apophysis. 



Angle of the jaw. 



Paths of Communication 
through which depletion 
Takes Place. 

Spermatic veins, circum- 
flex, iliac, and ileolum- 
bar veins. 

Portal vein, anal and peri- 
neal vessels, hemorrhoid- 
al veins. 

Uterine and hemorrhoidal 
veins. 

Prostatic and hemorrhoidal 
veins. 

Spermatic and inguinal 
veins. 

Pericardial and internal 
mammary veins. 

Bronchial and azygos veins 
and superior intercostal 
veins. 

Ophthalmic vein, cavern- 
ous sinus, petrous and 
lateral sinus. 



Application. — Leeches if singly applied may be placed on the skin 
under an inverted wineglass or under a large pill-box to prevent them 
from migrating before they take hold. If they will not take hold, a 
little sweetened milk may be placed on the skin or a drop of blood 
extracted from the finger may be placed there. In all cases the skin 
should be carefully washed before the leech is used. When the leech 
has taken enough blood, it can be made to let go its hold by sprinkling 
it with salt. Each leech will take about 1 drachm of blood. Leech- 
bites should be watched lest prolonged consecutive bleeding exhaust 
the patient. In case of such an accident, a compress and styptics are 
to be employed. As leech-bites make small permanent scars, the leech 
should not be applied on the face or other exposed surface of the skin. 



LUMBAR PUNCTURE. 

Lumbar puncture consists in the introduction of a strong hollow 
needle of large calibre, or a canula, with or without a trocar, between 
the third and fourth or fourth and fifth lumbar vertebra. In children 
a large needle without a trocar is nearly always adequate. The opera- 
tion can be performed when the patient is sitting up, with the spine 
bent by bending forward (see Tropacocaine), but is best done, particu- 



LUMBAR PUNCTURE. 615 

larly in children, with the patient lying on the side with the knees and 
hips flexed so as to separate the vertebras. The needle is introduced 
at the lower margin of the spinal column where the separation is 
greatest, unless the patient is lying on a hard table. The easiest way 
to find the level at which the puncture is to be made is to draw a line 
across from the crest of one ilium to the crest of the other. The direc- 
tion of the needle should be slightly upward and forward to a distance 
of about 2 centimeters (f inch) in children and 4 to 6 (1 \ to 2 inches) 
in adults. As soon as the subarachnoid space is reached the cerebro- 
spinal fluid will flow freely or even spurt out if the intraspinal pressure 
is abnormally high. Absolute surgical asepsis is, of course, essential. 
Therapeutics. — Spinal puncture is resorted to for three purposes — 
namely, treatment, diagnosis, and spinal anaesthesia. (See Tropaco- 
caine.) For treatment it is indicated chiefly in the convulsive seizures 
of children and in adults with uraemia. If convulsive seizures are 

Fig. 117. 




A, Space between the third and fourth lumbar vertebrse for subarachnoidean injection 
(Quincke's area) ; B, area of puncture suggested by Tuffier. 

recurrent, spinal puncture by giving relief to cerebrospinal pressure will 
arrest these in a fair proportion of cases. Usually about 15 to 20 mils. 
are withdrawn, but as much as 40 mils, or even CO mils, may be taken 
away. If the fluid is turbid it is a sign of infection of the meninges, 
most commonly by the meningococcus or by the pneumococcus, and if 
the infection is severe it may be not only turbid but yellowish or 
greenish. The sugar normally found present by the copper test is 
absent and a large number of polymorphonuclear cells are seen under 
the microscope. So, too, there will be found a marked increase in 
globulin. The diagnosis is confirmed by finding the specific organism. 
When the tubercle bacillus is the cause of meningitis the fluid is clear, 
there is an excess of small mononuclear lymphocytes and there is 
not a loss of sugar to so great a degree or an increase in globulin. 



616 REMEDIAL MEASURES OTHER THAN DRUGS. 

When the diplococcus of Weichselbaum is found, 30 mils, of the cere- 
brospinal fluid is drawn off and substituted by the same amount of anti- 
meningitis serum (see Antimeningitis Serum) daily until the fluid is 
clear and the patient convalescent. 

MINERAL SPRINGS AND CLIMATE. 

This article is intended to give the practitioner and student a gen- 
eral idea of where to send patients who can afford to resort to treat- 
ment depending upon watering-places and climates. It is manifestly 
impossible to include the names of all the health resorts, and the 
object is to indicate the diseases which are benefited by these treat- 
ments, taking certain well-known resorts as types of each class. 

Springs. 

Medicinal springs are usually resorted to for the double purpose 
of drinking and bathing in the waters, although in many instances 
one of these methods so far exceeds the other in popularity that it 
alone is employed. 

For general purposes we may divide these medicinal or beneficial 
waters into four classes — namely, those which act, first, by their 
purity chiefly; second, by the presence of more or less active alkaline 
ingredients; third, by the heat which the waters contain as they 
leave the earth; and, fourth, by the sulphur or radio-active substances 
which they contain. The first class — namely, those which act by reason 
of their purity — are indicated chiefly in cases where through high living 
or other cause the system becomes laden with impurities through 
imperfect elimination of tissue-waste. Most of the popular lithia 
waters depend chiefly upon this ability to dissolve effete materials, 
and very little upon the lithia, which is often present in very small 
amount. (See Lithium.) Aside from their purity, they also act by 
reason of the salts of sodium and calcium which they contain. Good 
results follow their use in the so-called uric-acid diathesis where the 
urine is scanty, high-colored, and acid. They do good in cases of 
irritable bladder by washing out this viscus with mild urine in large 
quantities, and because of this influence are credited with wonderful 
cures of vesical calculus. When vesical calculi have broken down 
while these waters were being taken, the fortunate result has been 
coincidence rather than due to medicinal interference. It is impos- 
sible for them to dissolve stones, but their constant use may prevent 
the formation of new ones. Perhaps the best representative of such 
waters is Londonderry lithia water. 

A subdivision of this class consists of those waters which contain 
somewhat larger amounts of mineral substances, chiefly potassium, 
sodium, and calcium salts. Because of the power possessed by alka- 



MINERAL SPRINGS AND CLIMATE. 617 

line salts in aiding in oxidation, these waters are used in cases where 
the effete matters of the body seem to escape only partly oxidized, and 
where the kidneys, and perhaps the liver, seem torpid. Such springs 
are the Kissingen and Vichy at Saratoga. If very mild purgative 
properties are also desired, the Geyser Spring at Saratoga may be 
used. In Europe the most famous springs of this class are at Vichy 
(Grande Grille), Vals, and Contrexeville in France, and Kissingen 
in Bavaria. 

The second class of springs are those which contain salts of sodium, 
calcium, potassium, and magnesium in sufficient amount to possess 
very active diuretic and purgative properties. They find their thera- 
peutic application in cases of hepatic torpor or congestion associated 
with gouty or rheumatic tendencies, particularly in those individuals 
who have been high-livers, who lay on too much fat, so clogging their 
organs, and, finally, in those who through illness or exposure to hot 
climates have subacute or chronic atony of the liver, of the organs 
of digestion, and of the lymphatics. Nearly always these patients 
also suffer from more or less constipation and gastro-intestinal catarrh, 
and are often obese. The sulphate of sodium is an ingredient of 
many purgative mineral waters, and the activity of a water depends 
very often on the percentage of this salt which is present. The pur- 
gative action of a water also depends upon the time at which it is 
taken. When taken on an empty stomach it is of course more active. 
When taken early in the morning before eating and at the natural 
temperature, such a water produces a loose watery movement, not 
only unloading the bowel of fecal matter, but by its alkalinity loosen- 
ing catarrhal secretions and unloading the liver of congestion. The 
quantity to be taken in twenty-four hours varies from 1 to 4 pints, 
but this question can only be decided by the local physician, who' 
studies the effect of the water on the patient. The best-known waters 
of this class are the Champion, Congress, Hathorn, and Carlsbad 
Springs at Saratoga, New York, the Crab Orchard in Kentucky, and 
the springs of Carlsbad and Marienbad in Bohemia, and Friederich- 
shall in Germany. These waters are chiefly used at the site of the 
springs, except Hathorn and Friederichshall which are bottled and 
used in this country. Of the sulphate purgative waters the best known 
are Hunyadi and Apenta from Hungary, and Pluto of Indiana. 
These are bottled for transportation and widely used. 

The hot springs depend chiefly on their heat, as already stated, 
and differ in chemical composition. They find their value in the 
treatment of chronic skin diseases, specific or otherwise, and also are 
useful in aiding in the treatment of rheumatism, gout, and syphilis. 
Their good results are produced by their heat, which varies from 
93° to 150° F,, and the advantages always derived from properly 
employed hydrotherapeutic measures. It is in chronic or subacute 
cases that they do the most good. Hot baths are also of great value 
in the treatment of chancroid and malignant syphilis. The results 



618 REMEDIAL MEASURES OTHER THAN DRUGS. 

achieved depend upon the increased activity of the skin, the im- 
provement of the peripheral circulation, and the increased powers 
of absorption of mercury produced through increased cellular 
activity. 

Patients should always select a competent local physician at such 
resorts. 

In cases of syphilis the methods of treatment to be followed are as 
follows: The patient should take the bath at a temperature of 90° F., 
and remain in it for about twenty minutes. After this he is rapidly 
but thoroughly dried by an attendant, who at once proceeds to rub 
into the skin of one thigh an amount of mercurial ointment varying 
from a few grains to a drachm. This is well rubbed into, not smeared 
over, the skin of a different limb after each bath. The number of 
baths and inunctions depends upon the condition and necessities of 
the case, care being exercised not to push the mercury too freely in 
those who are very susceptible to its effects. These baths also aid in 
the absorption of mercury when it is administered by fumigation. 
The most celebrated of these springs are the Hot Springs of Arkansas 
and those found at Aix-la-Chapelle (Aachen) in Germany. 

As types of the fourth class of springs we have the White Sulphur 
Springs in West Virginia and the Richfield Springs in New York, 
which are used for the relief of catarrhal inflammations of the mucous 
membranes of the alimentary canal and respiratory passages, and 
more rarely for catarrhal states of the genito-urinary tract. Not 
only do they exert the peculiar remedial powers long known to belong 
to sulphur and its compounds by reason of the sulphuretted hydrogen 
gas contained in them, but they also possess distinct purgative effects. 
Their chief mineral constituents consist of sulphate of sodium and 
magnesium, which unload the bowels and portal system in the same 
manner as do the Champion, Congress, Hathorn, and Carlsbad 
Springs at Saratoga and those at Crab Orchard. Taking the White 
Sulphur as a type of its class, it is better than the Saratoga springs 
in catarrhal states for the reason given. 

Rockbridge Alum Spring, in Virginia, is used in cases of chronic 
diarrhoea with very useful results in many cases. It is not so useful 
in acute inflammations of the intestine as in the diarrhoea due to 
chronic disorder. As iron is present in it and in most alum springs 
in considerable amount, this water is useful in anaemic cases, but is 
contraindicated by fevers, by chronic congestions, chiefly of the liver, 
and by plethora. Often in place of alum we find salines associated 
with the iron, and these waters are particularly indicated in the catarrhs 
associated with anaemia. Such a spring exists at Bedford, Pennsyl- 
vania. In Europe the chief iron springs are at St. Moritz in Switzer- 
land and Tunbridge Wells in England. Neither of these contains 
much sulphur or alum. 



MINERAL SPRINGS AND CLIMATES. 619 



Climates. 

The practitioner is most frequently consulted as to the possible 
benefit of climatic changes by persons suffering from pulmonary 
disease, such as tuberculosis of the lungs, asthma, chronic bronchitis, 
and emphysema — more rarely by those convalescing from pneumonia 
or other severe acute illness. 

The general rules to be followed in all cases are — first, choose 
a climate having as large a number of clear days as possible, in order 
that an out-of-door life in the sunshine may be had constantly; 
secondly, the nearest place to the home which is available in order 
to avoid fatigue, expense, and homesickness; and thirdly, see that the 
resort chosen has comfortable accommodations, good food, good drug- 
supplies, and a capable physician at hand in case of need. 

In a case of tuberculosis and in all patients suffering from the pul- 
monary complaints named above the following rules may be adhered 
to, except in persons suffering from attacks of acute bronchitis, who 

Fig. 118. 



Chest outline before residence at Davos •. After residence at Davos . 

William's diagram.) 

always need a climate providing moisture and warmth. Some tuber- 
cular patients do best in a high, dry air, and others in a lower and 
more moist temperature — the first being represented by that of Colo- 
rado Springs (6000 feet) or Silver City in America and by San Moritz 
(6000 feet) and Davos Platz (5000 feet) in Switzerland, where the alti- 
tude is not only very great, but the air very cold in winter. The days 
in these places are many of them clear, but in Colorado they are apt 
to be windy. Feeble persons cannot stand high winds, as a rule. 
The second climate is represented by that of Florida and Southern 
California. 



620 REMEDIAL MEASURES OTHER THAN DRUGS. 

In those cases in which a mild climate is useful, this can be obtained 
at San Diego, a place where there is virtually perpetual summer. At 
Asheville, N. C. (2200 feet), or Thomasville, Georgia (330 feet), the 
air is moderately dry. A spot is desirable where a patient can re- 
main the year round, and, if well enough, engage in business, avoid- 
ing the cold, sharp March winds of the Middle, Eastern, or North- 
western States, and the necessity of leaving Florida on the advent of 
summer. 

Physicians have attempted for years to formulate rules for phthisical 
patients as to the climate to be sought. In very many cases the 
various health resorts have to be chosen by experiment, not by judg- 
ment beforehand. In cases of phthisis with profuse bronchial secre- 
tion, a high, dry climate is generally the better unless the heart is 
feeble, but in cases which suffer from dryness of the air-passages a 
sea-voyage or a warm, moist climate is better, on general principles. 
It is probably true, however, that high altitudes and rarefied air are 
not to be sought where a distinct tendency to hemorrhage is present, 
unless the ascent or removal to the rarefied air is very gradual, several 
weeks being passed before the lung is exposed to the low pressure of 
great heights. The cases in which high altitudes do good are those 
which naturally have poor thoracic development or suffer from chronic 
pleurisy with deficient expansion of the lung after tapping. A high 
altitude not only improves respiratory capacity and develops the 
chest, but also increases the richness of the blood in its red cells as to 
number and as to their content of hemoglobin. The following excel- 
lent advice given by White in his General Therapeutics is worthy of 
repetition : 

"It is of such importance that only suitable cases should be sent 
to high altitudes that we must point out those that are unsuitable: 

"1. Those in whom there is considerable affection of the bronchial 
tubes, for the dryness of the climate increases the kind of bronchitis 
which commonly accompanies phthisis. 

"2. Patients with much emphysema or bronchiectasis, because of 
the probably diminished absorption of oxygen and the difficulty of 
respiration experienced on first arriving. 

"3. Patients with disease of the heart must not go to a high alti- 
tude, because of its effect upon the pulse and upon respiration. 

"4. Cases liable to acute febrile attacks, whether or not these 
indicate an occasional increase of mischief in the lungs, should remain 
on a low level. 

"5. Patients who are very excitable or suffer from insomnia should 
not go, for a visit to a place at a great elevation promotes these symp- 
toms. Women do not acclimatize so well as men. 

"6. Cases in which there are very extensive lesions, or which are 
very advanced, are unsuitable. 

"7. Pneumonic phthisis, if at all acute, is made worse by a high 
altitude. 



MINERAL SPRINGS AND CLIMATES. 621 

"8. Patients who cannot take exercise should not go. 

" 9. The very old and the very young had better be treated at home. 

" 10. Sir Andrew Clark states that patients who go to Alpine health 
resorts suffering from albuminuria, or those who develop it whilst 
there, seldom derive any good from their change. 

"There are many conditions which have been thought to contra- 
indicate this treatment, but which do not, and they had therefore 
better be mentioned. They are: 

"Pulmonary Hemorrhage. — It is now known that this, so far 
from being a contraindication to treatment by high altitudes, is actu- 
ally relieved by it. The exact explanation cannot be given." 

With this the author of this work cannot agree. 

"Fever. — If this is not excessive, and if it does not indicate any 
active changes in the lungs, it is often improved. 

"Simple Diarrhcea and Simple Dyspepsia. — These are both 
benefited. 

"Night-sweats. — There is a common belief that these forbid this 
treatment; on the contrary, they often disappear on removal to a high 
altitude. 

"The Presenxe of Cavities. — This is not a contraindication 
unless a very large area of lung is destroyed." 

There is no need, after these two lists, to say what cases are suit- 
able for this climatic treatment: it may, however, be observed that 
those in whom there is threatened phthisis, with a strong hereditary 
predisposition, and those of imperfect thoracic development, are 
much benefited. 

To these rules the author would add the following invariable rule: 
viz., Do not send a case away to die. If the disease is so far advanced 
that no good can be derived from a trip abroad, it is cruel to make a 
wretched patient exhaust his strength, his money, and his happiness 
by seeking health which it is impossible for him to obtain. A patient 
of the writer's returned on one occasion from a stay of a few days at 
a noted Southern resort for consumptives, and, when reprimanded 
for his imprudence, replied: " I would rather be at home, and die 
at once, than drag out a few more years surrounded by a crowd of 
coughing, hawking, and wasting consumptives." This reply evidences 
clearly the necessity of avoiding "consumptive hotels" as much as 
possible in these cases, and in directing the mind of the patient from 
depressing thoughts and his own ailment, and that he may avoid 
secondary infection from other sufferers. 

In the treatment of renal and cardiac disease high altitudes are 
contraindicated, as a rule. The chief desideratum is out-of-door life 
with avoidance of chilling of the skin by sudden changes in tempera- 
ture or strong winds. San Diego and many other places in Southern 
California represent the necessary climate in such cases. 

There is a class of persons who often have no actual disease of a 
chronic type, who nevertheless pass healthier lives if" away from rig- 



622 REMEDIAL MEASURES OTHER THAN DRUGS. 

orous climates for at least part of the year. Without having acquired 
tuberculosis, their lungs are delicate naturally or because of attacks 
of disease, or, again, they become asthmatic or rheumatic in cold 
weather. In this country Asheville, N. C, and Thomasville, Ga., or 
San Diego or Santa Barbara, California, afford the climate desired, 
while in Europe patients are sent to what is known as the "Riviera," 
which is the district bordering on the Mediterranean Sea from Genoa 
to Nice and which is dotted with climatic resorts. This district has 
often as many as two hundred clear days between October 1st and 
May 1st. In the French Riviera the resorts are Cannes, Nice, Monaco, 
Monte Carlo, and Mentone: in the Italian Riviera, Bordighera and 
San Remo. In Naples and Spezzia the climate is more damp and 
colder, but nevertheless quite sunny. So much depends upon the loca- 
tion of the hotels in these places, as far as their salubrity in relation to 
air and dampness is concerned, that the patient should always con- 
sult a local physician before settling down permanently at any of these 
resorts. 

PHYLACOGENS. 

This term "phylacogen" is applied to sterile aqueous solutions of 
derivatives of bacteria which have been grown on artificial media. 
No bacteria are present, because they are first killed and then removed 
by filtration through porcelain. The solution is also tested after this 
to be sure it is sterile. While, therefore, phylacogens differ materially 
from the so-called bacterins or vaccines in themselves (see Vaccine 
Therapy), the principal of their employment is practically identical 
in the sense that they are designed to stimulate the protective processes 
of the body to greater effort. They are closely allied to the so-called 
polyvalent vaccines because each individual preparation of phylacogen 
is composed of the products of a number of • pathogenic germs, with an 
excess of one particular germ which is known to be the chief cause of 
the disease from which the patient is suffering. The organisms used 
are the Streptococcus pyogenes, Bacillus pyocyaneus, Diplococcus 
pneumonia?, Bacillus typhosus, Bacillus coli communis, Streptococcus 
rheumaticus, and the Streptococcus erysipelatus. The product from 
a culture of these germs is called polyvalent or Mixed Phylacogen. 
The fundamental idea of this method is that in all acute infections, al- 
though one germ may be dominant, it has associated with it a host of 
others in smaller number which are aiding it in overcoming the patient. 

When it is desired to treat a specific illness, as, for example, acute 
articular rheumatism, a special culture of the specific germ is prepared 
and its filtrate is added in equal amount to the ordinary mixed phylac- 
ogen just described. The same process is followed when typhoid, ery- 
sipelas, croupous pneumonia, and other infectious diseases are to be 
treated. 

The product, however, is so dilute as not to be severely toxic, it 
being estimated that the lethal dose would be about eighty times the 
maximum ever given to a patient. 



PHYLACOGENS. 623 

These products give fully as good results as vaccine therapy, and 
seem to be peculiarly efficacious in acute and chronic rheumatism of the 
joints, gonorrhceal rheumatism, and in erysipelas and in pneumonia. 
Too often they are employed when the patient is so nearly dead that 
the case is hopeless. Manifestly two factors are needful in their use — 
namely, a correct diagnosis and enough vitality in the patient's tissues 
to enable him to react. 

Administration. — The phylacogens are given by means of a large 
syringe capable of holding 5 or 10 Cc. The syringe is filled from a 
hermetically sealed glass ampoule. The skin where the injection is 
to be given should be carefully sterilized, and as the injection is bulky 
the abdominal wall, the back, or the outside of the thighs should be the 
part chosen for injection. The injection should be made hypodermic- 
ally and not into the superficial fascia or into a muscle, and subsequent 
injections should be given in other portions of the body than the area 
of the first injection. In urgent cases the injection may be given intra- 
venously. This also holds true of cases which resist subcutaneous 
doses in the sense that no betterment follows their use. In a period, 
varying from one to four hours, after the injection subcutaneously 
there is a distinct constitutional reaction, the rise of temperature vary- 
ing from 1 to 4 or even 5 degrees, often preceded or accompanied by a 
chill and a sense of numbness. While these symptoms are alarming, 
they are fleeting and not followed by bad results. Simultaneously 
with the constitutional symptoms described the pulse may increase in 
speed 10 to 50 beats above the normal, and occasionally there may be 
some nausea and moderate diarrhoea. Occasionally, stomatitis or herpes 
has been observed. 

Locally, the injection results at the end of from six to twenty-four 
hours in redness and the part may be painful and tender. The first 
dose for hypodermic use is 2 Cc. increased daily to 10 Cc, according 
to the severity of the infection and the ability of the patient to stand 
a reaction. 

When given intravenously a sharp needle is attached to the syringe 
and, after the skin is sterilized, it is plunged into a vein, usually the 
median cephalic. The reaction following a full intravenous dose is 
usually quite severe, the face may be pinched, the lips blue, the pulse 
may be feeble and at times intermittent, and the respirations may be 
shallow and rapid. The reaction from an intravenous dose usually 
comes on within thirty minutes and is characterized by a severe chill, 
such as is seen in very severe cases of malarial fever. Because of the 
severe reaction when used intravenously, the first dose should always 
be given by the subcutaneous method to determine the ability of the 
patient to gain benefit from the effects of the remedy. 

When used intravenously the initial dose should be J to J Cc. The 
second dose 1 Cc, increasing 1 Cc for each subsequent dose, but not 
exceeding 5 Cc. The interval between doses is usually twenty-four 
hours. Very young or very aged patients should receive \ to \ the 
dose for adults. 



624 REMEDIAL MEASURES OTHER THAN DRUGS. 

Contraindications. — Where the patient is moribund or in a hopeless 
condition, or a sufferer from severe and dangerous cardiac disease or 
advanced arterial and renal disease, phylacogen should be used with 
caution, if at all, and never given intravenously. Nephritis is also a 
contraindication. If cyanosis is great after the first injection, the 
subsequent ones should be smaller. 



POLLEN PROTEINS. 

It seems to be pretty well determined that the multiple symptoms 
covered by the general term "hay fever" are due to the entrance into 
the respiratory tract of protein substances which are derived from the 
pollens of the flowers and various grasses, shrubs and trees. In other 
words, such patients are sensitized to these protein substances and 
react to them as does a patient who has been sensitized by the injection 
of protein substances derived from blood serum. 

Acting upon these basic facts the attempt has been made to protect 
so-called hay-fever patients by prophylactic injections of, and to 
treat the disease when already in existence by, derivatives of various 
forms of pollen. The two pollens which most commonly induce hay 
fever are timothy pollen in the spring, and ragweed pollen in the 
early autumn, although it is possible for a patient to suffer from 
timothy hay fever late in the season and ragweed hay fever earlier 
than the usual time in August or a combination of both. 

It is essential to determine which pollen is responsible for the symp- 
toms. If timothy pollen is responsible, the use of its extract is indi- 
cated, and if ragweed pollen is the cause of the disease, ragweed pollen 
extract is to be used. In cases in which the symptoms persist and 
are probably due to both pollens, an extract composed of both of them 
may be employed. 

The extracts come on the market in three strengths expressed in 
units, viz.: 10 units, 100 units, and 1000 units to each milliliter 
accompanied by a fourth bottle containing a diluent salt solution 
whereby small quantities of the extracts can be prepared for use. The 
unit is an arbitrary one and is that quantity of pollen toxin that can be 
extracted from the thousandth part of a milligram of phleum pollen. 
The object of having these different strengths is to enable the physician 
to determine the dose which should be given as a prophylactic or cura- 
tive measure. The physician must determine not only if the patient 
gives the reaction but also how small a dose will accomplish this result. 
Half a cubic centimeter (mil.) of Extract No. 1, containing 10 units 
is drawn up into a syringe, such as is used for the injection of tubercu- 
lin, and this is diluted by filling the syringe from the bottle marked 
diluent. This solution now represents 5 units. If the intradermic 
test is to be used, one or two drops of this solution is injected into the 
skin, not under it, and if the spot injected becomes in about five 
minutes a raised patch, white in the centre but with a red areola, and 



REST CURE. 625 

lasts for a half-hour or hour, it is considered that the reaction is positive 
to that particular pollen and its further use is indicated to protect 
or cure. Another test is to scarify the skin of the arm, as in vaccina- 
tion, and apply a drop of the prepared solution to the spot, rubbing it 
in well, when a similar reaction develops in susceptible patients. If 
these weak tests fail, 0.2 mil. of 100-unit extract is diluted to 1 mil. and 
employed in the same manner, or as a stronger test 0.3 mil. of 1000- 
unit extract is diluted to 1 mil. If one pollen extract fails, the other 
should be tested. 

Having determined the strength of the solution needed to induce 
a reaction the physician, if he is giving prophylactic treatment, then 
injects hypodermically one-third of a cubic centimeter (mil.) (0.3) of 
the particular solution and repeats the injection every three or four 
days according to the severity of the reaction at the spot injected, 
increasing the dose at each treatment so that by the fifth injection 
the patient receives 1 mil. of the 10-unit extract. iVt the sixth injec- 
tion 0.2 mil. of the 100-unit extract is used and at the tenth treatment 
1 mil. of it is given. The eleventh injection, provided the previous 
local reactions are not too severe, consists in using 0.2 mil. of the 1000- 
unit extract, and the fifteenth consists in injecting 1 mil. of this the 
strongest extract. Some physicians use these quantities of extract 
without diluting them. 

The treatment, as already stated, is both prophylactic and curative. 
The first dose for prophylaxis should, if possible, be used at least 
one month before the expected onset of the disease. When used to 
treat hay fever already present, the physician must first determine 
the smallest amount of diluted extract that will cause reaction and 
then begin with one-tenth of this amount and gradually increase 
the doses as above, being governed by the severity of the reactions, 
which often consists in marked itching and burning at the site of the 
puncture. Care should be exercised not to give an injection any- 
where near the site of a former puncture. When it is believed that 
more than one pollen is responsible for the attack, a combined extract 
is used. 

The results obtained have been good in a sufficiently large number 
of cases to justify the employment of this plan in those who suffer 
severely from hay fever. Unfortunately the treatment has to be 
repeated every year to give relief, and extracts of all the pollens capable 
of causing hay fever are not to be had except in combination on the 
same principle as a multiple vaccine. 

REST CURE. 

The rest cure, so called, is a method devised and elaborated by Dr. 

S. Weir Mitchell, of Philadelphia, for the relief of a large class of 

patients who, for various reasons, are generally ailing from apparently 

no organic disease, and yet whose condition is often so alarming as to 

40 



626 REMEDIAL MEASURES OTHER THAN DRUGS. 

lead to the belief that some hidden cause of a severe train of symptoms 
must be present. In many such instances a careful study of the case 
will show that there is a cause, near or remote, which has exhausted 
the patient's vital forces without producing anything else than func- 
tional disturbances of the body. Thus a prolonged nerve-strain in 
nursing a sick relative may so exhaust the strength of a hitherto healthy 
woman as to produce hysteria, anaemia, and great disturbances of 
nutrition, or, in another instance, cause neuralgia, disordered men- 
struation, and uterine or ovarian pain. In males, mental, sexual, or 
physical vigor may be impaired, owing to prolonged anxiety in busi- 
ness. Be the symptoms what they may, as long as they are depend- 
ent upon nerve-strain, this "cure " is to be resorted to, and if properly 
carried out is often attended with surprising results. It is also a valu- 
able means of treating functional and organic heart disease. Before 
describing the method in detail it is proper to state that its entire 
rationale rests upon the remembrance that every movement is an ex- 
penditure of force, and that a system which has already overdrawn 
its reserve fund of strength must be as careful with its funds that 
remain as a bank should be under the same circumstances. 

It having been decided that the rest cure is to be employed, the 
directions are given as follows: 

A bright, airy, easily cleaned, and comfortable room is to be selected, 
and adjoining it, if possible, should be a smaller one for an attendant 
or nurse. The patient is put to bed and kept there for from three to 
six weeks, or longer, as may be necessary, and during this time is 
allowed to see no one except the nurse and the doctor, since the pres- 
ence of friends requires conversation and mental effort. The patient, 
in severe cases must be fed by the nurse in order to avoid the expendi- 
ture of the force required in the movement of the arms. No sitting 
up in bed is allowed, and if any reading is done it must be done by 
the nurse, who can read aloud for an hour a day. 

In the case of women the hair should be dressed by the nurse to 
avoid any physical effort on the part of the patient. 

To take the place of ordinary exercise two measures are employed, 
the first of which is massage or rubbing of the body, the second elec- 
tricity. By the kneading and rubbing of the muscles and skin the 
liquids in the tissues are absorbed and poured into the lymph-spaces 
and a healthy blush is brought to the skin. This passive exercise is 
performed in the morning or afternoon, and should last for from a 
half to one hour, every part of the body being kneaded, even the 
face and scalp. In the afternoon or morning the various muscles 
should be passively exercised by electricity, each muscle being made 
to contract by the application of the poles of the battery to its motor 
points, the slowly interrupted current being used. Neither of these 
forms of exercise call for any expenditure of nerve-force, though they 
keep up the general nutrition. The following programme for a day's 
existence is an example of what the physician should order: 



TRANSFUSION. 627 

7.30 a.m. Glass of hot or cold milk, predigested, boiled, or raw, 
as the case requires. 

8 a.m. The nurse is to sponge the patient with tepid water or with 
cold and hot water alternately, to stimulate the skin and circulation, 
the body being well wrapped in a blanket, except the leg or portion 
which is being bathed. After this the nurse should dry the part last 
wetted with a rough towel, using some friction to stimulate the 
skin. 

8.30 a.m. Breakfast. Boiled, poached, or scrambled eggs, milk 
toast, water toast, or a finely cut piece of a mutton-chop or chicken. 

10 a.m. Massage. 

11 a.m. A glass of milk, or a milk-punch, or egg-nog. 

12 M. Reading for an hour. 

1 p.m. Dinner. Small piece of steak, rare roast beef, consomme 
soup, mutton broth, and any one of the easily digested vegetables 
well cooked. 

3 p.m. Electricity. 

4.30 p.m. A glass of milk, or milk-punch, or egg-nog. 

6.30 p.m. Supper. This should be very plain, no tea or coffee, but 
toast and butter, milk, curds and whey, or a plain custard. 

9.30 p.m. A glass of milk or milk-punch. 

In this way the day is well filled, and the time does not drag so 
heavily as would be thought. If the stomach rebels at overfeeding, 
the amounts of food must be cut down, but when all the effort of the 
body is concentrated on respiration, circulation, and digestion a large 
amount of nourishment can be assimilated by the exhausted body, 
which before this treatment is undertaken may have had its resources 
so shattered as to be unable to carry out any physiological act per- 
fectly. 

For the treatment to be successful the rules laid down should be 
rigidly followed, and the cure should last from three to six weeks or 
longer. 

TRANSFUSION. 

The term transfusion is used in medicine to signify the transfer of 
blood from one person to another, whereas an intravenous injection 
is one in which other fluids than the blood are introduced into the 
vascular system. (See Intravenous Injections.) Transfusion is indi- 
cated in the following conditions: 

1. Anaemia of a severe degree due to acute haemorrhage arising from 
any cause. 

2. In severe anaemia arising from a prolonged loss of blood from any 
lesion. 

3. In cases of severe anaemia induced by haemorrhage depending 
upon hemophilia or blood dyscrasia when the donor's blood not only 
supplies normal blood but the element which will induce proper 
coagulation. 



628 REMEDIAL MEASURES OTHER THAN DRUGS. 

4. In pernicious anaemia for temporary relief and to prolong the life 
of the patient. 

There are four difficulties which stand in its way. 

1. To find a donor. 

2. To find a donor whose blood will not agglutinate the blood 
corpuscles of the donee. 

3. The prevention of clotting during the transference. 

4. The difficulty of dealing with the vessels of the donee, which 
vessels are often collapsed, very easily torn, or buried in fat. 

The first difficulty is overcome by friendship or cash. The second 
by testing the blood of the prospective donor until one is found which 
is compatible. The third by the use of a paraffin covering of the 
canulse employed, or by the mixing of the blood with some anti-coagu- 
lant, such as sodium citrate solution. The fourth by technical skill 
and the choice of suitable bloodvessels in a given case. 

For the determination as to suitable blood the following test 
devised by one of my former pupils, Dr. John Funke, may be resorted 
to. A small amount of blood is taken from a vein of the donee and the 
corpuscles separated by the use of a centrifuge. The serum, in the 
proportion of 5 parts to 1 part of the whole blood of the donor, is 
thoroughly mixed. A drop or two is placed on a cover-glass which is 
then inverted over the excavation in a drop culture slide and this 
circled with oil to prevent drying. If the blood of the donee and donor 
is incompatible the corpuscles will clump or agglutinate and another 
donor must be found. 

The blood of the donor should also be tested by the method of 
Wassermann to exclude syphilis; any statement of the donor as to 
his freedom from syphilis being liable to error, particularly in the 
case of paid donors. 

If the question of subsequent transfusions be considered at a later 
date it is proper to make the agglutination test a second time, even 
when the same donor is employed, and if ten days to two weeks 
have elapsed the danger of anaphylaxis is to be considered. This can 
be avoided by the earlier use of each subsequent injection and by 
Besredka's test described in the article on Antitoxin. 

It is becoming increasingly evident that the simplest method of trans- 
fusion is the best. This is that of Lindeman. It consists in having 
several 20 Cc. Record syringes with suitable needles. These needles 
are in reality small canulas with a trocar having a sharp bevelled 
point so that the wall of the vein is readily punctured. The needles 
are coated with sterile liquid albolene by drawing up and expelling 
the oil, using an extra syringe to thoroughly clear the needles of any 
excess of the oil. After the puncture the trocar is withdrawn so that 
the blunt end of the canula does not wound the inner wall of the 
vein. As soon as the trocar is withdrawn blood appears and a syringe 
loaded with warm saline should be used to push back the blood from 
the canula if the vein of the recipient or donor, as the case may be, 



TRANSFUSION. 629 

is not ready. After each injection of blood the canula in the donor's 
vein is washed clear of blood by a small amount of normal saline to 
prevent the blood in the canula from clotting before the next injection 
can be given. One syringe having been partly filled with normal saline, 
a large vein in the arm of the donor is punctured and the piston with- 
drawn slightly to see if blood flows. It it does, proving that the vein 
has been entered, the syringe is filled with blood. At the same time an 
assistant punctures the vein of the donee, with a needle attached 
to a syringe, the barrel of which is also partly filled with saline and the 
same test is made to be sure the needle is in the vein. The syringe 
full of blood is handed to the assistant who hands back an empty one 
to the operator who in turn fills it as the assistant injects the blood. Time 
is saved by using a third syringe as a go-between. Each syringe as 
emptied is washed out with sterile saline before being filled a second 
time, preferably by a second assistant. Lindeman states he has done 
this many hundred times without any but good results. When the 
patient is restless it is best to expose the vein, nick it with scissors and 
use a canula which fits the syringe and has a shoulder to hold it in the 
vein by the tying of a ligature. In infants it is almost impossible to 
use a vein in the arm. The needle in such cases should be passed into 
the longitudinal sinus in the middle line at the posterior extremity of 
the fontanelle and the blood of the donor injected at this point, or 
the jugular vein used. 

If the physician is afraid to use this plan lest a clot form, he may 
bleed the donor into a flask of 100 mils, capacity in which is placed 10 
mils, of a 2 per cent, solution of sodium citrate, stirring the blood and 
citrate solution very gently with a glass rod. This flask should be 
kept warm by immersing it in hot water. Its contents may be drawn 
up in a large warm glass syringe and injected by means of needle or 
canula. If need be this blood may be kept several hours before using. 
In ordinary cases the small amount of citrate is harmless, but in 
hemophiliacs I would be afraid of it. 

If direct transfusion from artery to vein is desired the following 
plan may be employed, using a modification of Fauntleroy's vein to 
vein to canula. The modification consists in having the arterial end 
of the tube smaller than the venous end. Several tubes of different 
sizes should be ready and at hand to be sure of a proper size when 
the vessels are exposed. 

This glass cannula is coated on its inner surface with paraffin to pre- 
vent clotting. For this purpose Gruber's filtered paraffin (melting-point 
60° to 62° C), 56 parts by weight, and pure white petrolatum 44 parts 
by weight are heated together to 120° C. and kept at this temperature 
one hour so as to sterilize the mixture. When the mixture is cooled to 
about 50° C. the cannula is dipped in it, care being taken that no mois- 
ture is on the glass. In place of the mixture of paraffin and petro- 
latum Stanolind Surgical Wax, which melts at 47° C. may be employed 
without petrolatum. Care must be taken that no excess of paraffin 
remains in the calibre of the cannula to block it. 



630 



REMEDIAL MEASURES OTHER THAN DRUGS. 



The ordinary asepsis being practised the surgeon exposes the radial 
artery, places a clip on its proximal part and a. ligature on the distal 
part. Another ligature is run under the artery and by means of fine 
pointed sharp scissors the wall of the vessel is snipped. The smaller 
end of the sickle-shaped cannula is inserted and the loose ligature tied 
down over its shoulder. The vein of the donee, usually the median 
cephalic or basilic, is now exposed and a clip is placed on the vessel 
above and below the point where the vessel is to be cut. The narrow 
table carrying the donor is placed alongside that of the donee so 
that the patients' arms lie hand to hand. This is the best plan and 
is to be resorted to if suitable vessels in the right arm of the 
donee and left arm of the donor are found available or vice versa. 



Fig. 119. 




Artery to vein glass cannulas: A, arm to shoulder tube; B, shoulder to shoulder tube. 



When the vessels of the donor and donee are on the same side of the 
body of each the head to foot plan must be followed and the S-shaped 
tube employed. The advantage in using this S-tube instead of a 
straight one lies in the fact that the glass does not enter the vessels 
at an angle which if slightly increased may injure the vessel wall or 
obstruct its lumen. A ligature is run under the vein of the donee, the 
vein is nicked with scissors and the large free end of the canula is 
inserted toward the trunk, and tied in place. The clip is then removed 
from the donor's artery and the proximal clip from the donee 's vein and 
the flow takes place. (For the use of saline and other solutions given 
intravenously see Intravenous Injections.) If vein-to-vein transfusion 
is desired, Fauntleroy's tubes are employed, but the one-curve tube 
is used for hand-to-shoulder position and the S-shaped tube for the 
hand-to-hand position. In preparing the tubes care must be exercised 
in making the shoulders in the glass that proper annealing occurs, as 
otherwise the glass is so brittle that it will break and wound the vessels. 



VACCINE-THERAPY. 631 

VACCINE-THERAPY. 

Vaccine-therapy consists in the injection into the subcutaneous tis- 
sues of dead germs identical with those living germs inducing the dis- 
ease; the introduction of living germs being dangerous for obvious 
reasons. 

The term vaccine-therapy is a misnomer, iD that it conveys the idea 
that the method of cure consists in treating the patient by scarifying 
the skin and inoculating the patient with living germs, as in the process 
by which we immunize a person to small-pox by means of cow-pox virus. 
It is also a misnomer because it leads to the belief that some part of 
the process has to do with a calf or cow ("vacca," a cow), when, as a 
matter of fact, this animal is not even remotely connected with it. 
Again, it is a misnomer because, as a rule, dead germs are inocu- 
lated. A better term would be inoculation-therapy, but the phrase 
vaccine-therapy is so well established that it has probably come to 
stay. 

It is absolutely essential that the germs used, or the toxins used, be of 
the same kind as the organism already producing the abnormal state, 
and not only must the organism be of the same kind, but often of the 
same strain if it is to be effective. Because the introduction of 
these germs renders the already present invaders susceptible to phago- 
cytosis, or, in other words, makes them fit to be devoured, it is 
said that opsonins are developed in the blood, or tissues, from 
the Greek word onaova^, "I cater for," or "I prepare food," and 
for this reason vaccine-therapy is often correctly termed "opsono- 
therapy." 

Physiological Action. — Among the vital processes by which the body 
protects itself from invading micro-organisms is 'phagocytosis, or the 
swallowing and destruction of germs by those white blood-cells which 
possess this function as a result of which they are called phagocytes. 
If the body is in health and the invading army of germs is not too large 
or too virulent, so many of the invaders are overcome by this and other 
protective measures that illness does not occur, or, if it does, recovery 
ensues. Conversely, if the phagocytes are not up to their work, illness 
and death may ensue. 

When a suspension of dead bacteria in sterile normal salt solution is 
injected subcutaneously or intramuscularly, certain definite processes 
ensue. The body contains in its cells and juices a ferment or substance 
which possesses the power of dissolving bacteria. This complement 
cannot act, however, without the aid of another factor called an ambo- 
ceptor, which serves to connect or link the complement to the bac- 
terium. The amboceptor is produced by the body as a result of ; the 
injection (Effect 1). When it links the complement to the bacterium 
the latter is dissolved or disintegrated (lysis) (Effect 2), and the poison 
in the cell is set free (Effect 3) . This poison develops a factor (opsonin) 
(Effect 4) which renders the living bacteria in the body susceptible 



632 REMEDIAL MEASURES OTHER THAN DRUGS. 

to the attacks of the phagocytes (Effect 5) . The phagocytes devour- 
ing the bacteria set free their poison (Effect 6) , and this poison in turn 
produces more opsonin (Effect 7). This poison also induces the 
development of additional protective measures, namely, the appearance 
of increased bacteriolytic power (Effect 8) and, again, it stimulates 
the production of antitoxin (Effect 9). 

An examination of the phagocytes, when brought into the pres- 
ence of the infecting germ under the microscope, shows that at first 
their ability to destroy the invaders is somewhat decreased, and 
this is called the "negative phase"; but later they rally, the germs 
are rendered more susceptible, and phagocytosis is very active — 
the "positive phase." It is, therefore, evident that for the accu- 
rate application of vaccine-therapy the physician must be skilful 
in the examination of the blood and in bacteriological methods, that 
he may study phagocytosis and differentiate and then cultivate the 
specific germ which is causing the infection. Furthermore, it has been 
found that the skill to determine opsonic activity is so great that even 
those who work at it constantly often fail to get accurate results. For 
this reason accurate vaccine-therapy is limited to those who are so 
situated that a competent bacteriologist and opsonic estimator is at 
hand to assist. The result is that accurate or precise methods have to 
be cast aside in many cases, the physician sending a specimen to a 
laboratory to have the kind of infecting organism determined, and then 
injecting into the patient a "stock vaccine," that is, one put up by deal- 
ers in biological products, or he waits until the bacteriologist not only 
determines the germ, but grows it by cultural methods, and provides 
the physician with what is called an " autogenous vaccine " ; that is, one 
made from the patient's own germs. The number of dead organisms 
in a given quantity of salt solution is stated on the label, and the dose is 
gauged by this means (see Dosage). It is evident, from what has been 
said above, that at the best this plan of treatment is open to many 
chances of failure, and it is also to be borne in mind that if the patient 
is in a state of very low vitality because of the existing infection, or 
because of an antecedent illness, he may be damaged by an injection, 
because the "negative phase," or period of decreased phagocytic 
activity, may be exaggerated, and the "positive phase," or increase in 
phagocytosis, may never occur. In other words, we push the drowning 
man under water instead of stimulating him to increased effort to save 
himself. In the presence of very grave infectious illness, therefore, 
vaccine-therapy is not permissible unless a competent worker in opsonic 
estimation is able to assure us that the tissues of the body are capable 
of preparing the germs for phagocytosis. 

There is, therefore, a marked difference between vaccine-therapy and 
serum-therapy. In the former we stimulate the body to develop sub- 
stances with which to aid in its protection; in the latter, we give the body 
antitoxic substances already prepared by another and healthier ani- 
mal. Furthermore, it commonly happens that the patient is infected 



VA CCINE-THERAPY. 633 

not only by one organism, but different strains of that organism, or by 
a number of different micro-organisms. It, therefore, becomes neces- 
sary to employ a vaccine that represents all the strains or kinds present. 
When only one strain is present it is called a univalent vaccine, when 
more than one strain is used it is called a polyvalent vaccine, and when 
the vaccine is composed of more than one organism it is called a " mixed 
vaccine." Because of lack of laboratory facilities physicians often 
use a mixed or a polyvalent vaccine in the hope of hitting the offend- 
ing germs, as in the old "shot-gun" prescription. They also are often 
forced to use stock vaccines for the same reasons, and while this cannot 
be considered accurate, it is the best thing that can be done in many 
instances. In any event the kind of germ causing the illness must be 
determined, as otherwise the treatment is futile and may be even harm- 
ful. Then, too, it is to be recalled that in most cases there are infec- 
tions associated with the main infection, and this justifies the use of a 
mixed vaccine if the associated germs are isolated with the chief agent. 
This is notably the case in acute catarrhal conditions of the mucous 
membranes of the upper respiratory tract. In these states a multiple 
mixed vaccine is employed, containing as its chief agent the staphylo- 
coccus, with the streptococcus, pneumococcus, the micrococcus catarrh- 
alis, the bacillus of Friedlander, and the bacillus of epidemic influenza. 
Few persons are willing to submit to prophylactic injections to prevent 
colds, and after a cold is begun the use of such a vaccine seldom cures 
in less time than is usually consumed in getting well. 

Without doubt those infections due to the staphylococcus pyogenes 
aureus and albus are the ones which yield best to vaccine-therapy. 
As, for example, certain types of acne pustulosa and furunculosis, 
wound infections, cellulitis, and abscess in the subcutaneous tissues. 
If the acne is due to the bacillus acne, that specific vaccine must be 
used. 

When the infectious process is due to streptococci the results of vac- 
cine-therapy are often disappointing, perhaps because this micro- 
organism occurs in many different strains. The best results have been 
obtained from the use of autogenous antistreptococcus vaccine in puer- 
peral sepsis, and in localized or limited infections rather than in wide- 
spread infection of the entire system. Nevertheless, in erysipelas., which 
is a local and general infection by the streptococcus, this plan of treat- 
ment nearly always fails. 

In pneumococcus infections the results are fair if the treatment is 
used carefully. It gives less good results in pneumonia than in 
localized pneumococcic infections elsewhere than in the lung. 

In typhoid fever vaccine-therapy may modify the severity of the dis- 
ease, but it does not shorten its duration. 

In infections by the Bacillus coli, as in the kidneys and bladder, 
vaccine-therapy often gives excellent results, and in all forms of gono- 
coccus infection save in acute gonorrheal urethritis it is often very 
effective. (See also Antigonococcic Serum.) 



634 REMEDIAL MEASURES OTHER THAN DRUGS. 

Dosage. — This differs in different infections and in different cases. 
Unlike antitoxic serum, which should be in large dose in direct propor- 
tion to the gravity of the illness, vaccines, when they are first used, have 
to be given in inverse ratio to the gravity of the illness for reasons 
already stated. A high fever contraindicates their use. 

Having determined the kind of infection, the general state of the 
patient should be considered and, if possible, his "opsonic index" 1 de- 
termined. If he is very feeble, the early doses should be very mod- 
erate, and if he appears worse after their use the size of the dose must be 
decreased. 

In general terms the doses of the several vaccines for curative pur- 
poses are approximately as follows : 



100,000,000 to 1,000,000,000 at a dose. 

5,000,000 to 200,000,000 at a dose. 

5,000,000 to 500,000,000 at a dose. 
10,000,000 to 200,000,000 at a 
500,000,000 to 2,000,000,000 at a 



Staphylococcus 
Streptococcus 
Gonococcus 
Bacillus coli 
Bacillus pertussis 

The dose is given according to need; that is, only when the phago- 
cytic power, after its increase, is on the wane ; if the opsonic index can- 
not be had, then as soon as the patient fails to continue to improve. 
Very rarely are the doses given oftener than every day, usually every 
second or third day. The dose is increased only when the dose pre- 
viously given fails to produce increased phagocytic power or the 
patient fails to get better. If he is very ill, they should be reduced or 
they may overwhelm him. The more acute the illness, the less of the 
dose. If the reaction consists in a chill, vomiting and collapse, the 
dose is far too large. 

In gonorrhceal infection the dose is repeated about every four or five 
days. When pertussis vaccine is employed the dose should not be 
repeated in less than five days. It does not seem to modify the dis- 
ease as much when it is used early as it does when employed after the 
malady is well developed. Nevertheless, in infants in whom the dis- 
ease is nearly always serious it should be employed from the start. 

In all cases the injection is given in some part of the body not well 
endowed with sensation, yet well supplied with vessels and lymphatics, 
as the belly wall or back. Intravenous injections are not used because 
they may overwhelm the patient, and there is reason to believe that the 
specific substance is produced locally in the tissues and carried away by 
the blood or lymph stream. Indeed, it has been suggested that the 
best results will follow several small injections, in different areas, at one 
time, than when one single large dose is given in one place, since several 
foci for the production of complement or other useful substances will 
thereby be established. 

Prophylactic vaccine-therapy is carried out to protect persons who 

1 The opsonic index is the difference between the ability of the phagocytes of the 
patient and the phagocytes of a healthy person to destroy, or consume, a number of the 
specific organisms present in a given time. 



VACCINE-THERA P Y. 635 

may be, or have been, exposed to certain common infectious diseases. 
Thus, typhoid fever can be entirely prevented in armies and in hospital 
attendants by this means. The dose injected is about 500,000,000 
followed in seven days by another dose of 500,000,000, and a week 
later by another dose of 1,000,000,000. The best point for injection 
is in the loose tissues below the clavicle or into the outer aspect of 
the arm, not intramuscularly. In less than twelve hours a local 
reaction develops and nearby lymph nodes may become swollen. 
No general symptoms may develop, but commonly a slight febrile 
movement and languor, lasting for a day after the first dose, is pro- 
duced. Antityphoid vaccine is contraindicated in the weak and 
feeble, in menstruating women, and in the presence of any febrile 
process. When used the individual must abstain from all alcoholic 
drinks. Typhoid vaccine is not curative. In order to protect not only 
against typhoid fever but against the paratyphoid bacillus A and B, a 
vaccine made up of 500,000,000 typhoid bacilli and 250,000,000 each 
of the paratyphoid type is now generally used in order to protect 
against all these infections. When antityphoid inoculation is given a 
child between seven and twelve years, one-quarter of adult dose is used, 
one-half from twelve to fifteen years, and two-thirds from fifteen to 
eighteen years. For prophylactic purposes ordinary vaccines are best, 
but if vaccines are used to combat typhoid fever already developed it 
would seem best to use sensitized vaccines. 

It would seem probable that pertussis vaccine is more effective as a 
prophylactic than a cure, although when used as a cure the disease 
course is shortened about 33 per cent. 

Scarlet fever has been prevented by streptococcus vaccine, but the 
statistics are, as yet, uncertain. 

All these vaccines are now placed on the market in glass bulbs or 
in syringe containers ready for immediate use. The syringe container 
is the best form, as the barrel is so marked that any dose less than its 
full contents can be measured by pressing on the piston without ex- 
posing the contents, When a large number of persons are to be treated, 
as in the use of antityphoid vaccination, the suspension of bacilli is 
kept in a sterile bottle covered with a rubber diaphragm, through 
which the needle of a hypodermic needle is plunged and the dose of 
suspension withdrawn. 

Sensitized Vaccine. — Sensitized vaccine is one in which the specific 
bacteria producing a disease have been brought in contact with and 
have absorbed, or united with, antitoxin produced in an animal by the 
introduction into its body of the toxin of the same micro-organism. 
This immune serum is identical in its effect with that of the ambo- 
ceptor already described, and therefore the body of the patient does 
not have to produce an amboceptor before the complement can begin 
its process of dissolving the germ. It is to be understood, however, 
that the use of a sensitized vaccine is not equivalent to the use of 
vaccine treatment plus antitoxin treatment. 



636 REMEDIAL MEASURES OTHER THAN DRUGS. 

It has been proposed to use living sensitized bacteria on the ground 
that as they are sensitized the tissues can attack and destroy them 
before thev can multiply sufficiently to do harm. So far, however, this 
is considered dangerous because, unless the sensitization is so nicely 
adjusted that the protective processes can act at once, the patient 
may have added to his old infection a new infection. 

The advantages of sensitized vaccines over ordinary vaccines 
consist in the following points, so far as we can tell from experiments 
on animals and limited tests on man: 

(a) They cause little or no reaction or inflammation at the point 
of infection. 

(b) They are less prone to produce systemic symptoms, such as fever 
and general wretchedness, although the exact reason for this is not very 
clear. 

(c) Because of (b) they can be given in large doses and more fre- 
quently. 

(d) They develop immunity or protection more rapidly. 

(e) Because of (b) they can be used in cases in which the illness is 
more severe without so much danger of the "negative phase" being 
unduly prolonged or so severe that the positive phase is never reached. 

The sensitized vaccines possess the disadvantage that the immune 
serum used to sensitize must be produced by exactly the same bac- 
terium as that injected and that infecting the patient, in order to com- 
bine with the bacterium used for injection. If this is not the case the 
injection is no better than ordinary vaccine. In acute illness there is 
not time, as a rule, to prepare even an autogenous vaccine, still less to 
make immune serum. In other words, in most instances, we use a 
"stock sensitized" vaccine, so-called, hoping that it has been provided 
with the proper amboceptor. 

Dosage. — For the reasons just given, the doses of sensitized vaccine 
are, theoretically, considerably in excess of ordinary vaccines, but 
it is safer to begin with ordinary vaccine doses and increase rapidly 
if no reaction ensues. 

Vaccine therapy has not stood the test of clinical and laboratory 
investigation as well as it was hoped it would. At times it seems to 
give excellent results in an individual case and, again, utterly fails. 
In some instances this is due to the use of a different strain of organism 
from that inducing the disease, to the presence of mixed infection, or 
to the dose being too small to do good or so large as to decrease rather 
than increase vital resistance. In other words, the primary negative 
phase may be too severe and the patient never gets the secondary 
positive phase or benefit. While on the one hand autogenous vac- 
cines seem to give the best results, on the other hand it has been 
shown that the injection of any foreign protein or toxin may seemingly 
cause such an arousing of the vital processes as to result in cure. 
When two large series of cases of a given disease are tested, one with 
vaccine and one without, and every element of fallacy which can be 



VENESECTION. 637 

excluded is excluded it frequently happens that the non-vaccine cases 
show a better percentage of recoveries than those receiving vaccine. 
The writer believes that the field of efficiency of so-called vaccines 
is constantly narrowing and that before long this plan of treatment 
may be perhaps considered obsolete. Nevertheless so many observers 
claim good results from vaccines that the text of the preceding pages 
appears out of respect for their views rather than because the author 
has faith in the measures advised. These pessimistic remarks deal with 
the vaccine treatment of infections already developed; not with pro- 
phylaxis by vaccines to prevent typhoid fevers. 

VENESECTION. 

Bleeding, or phlebotomy, is so rarely practised to-day that very 
many of the profession have never abstracted blood for therapeutic 
purposes or have even seen it done by someone else. Furthermore, 
it is to be feared that many of the younger physicians would hardly 
know how to bleed if called upon to do so at a crisis. All this is 
wrong, for bleeding is a measure undoubtedly of the greatest value, 
and one which every physician may be called upon to resort to. Like 
many therapeutic measures, it was sadly abused in the early part of 
the last century, and people when taken ill were bled with the same 
regularity that they were put to bed. 

The indications for venesection are as clear and well defined as are 
the indications for any remedy. Briefly stated, we may say that all 
states of the circulatory apparatus denoting high arterial tension and 
acute excitement are indications, and that weakness, low arterial 
tension, and systemic or circulatory depression are contraindications, 
but the chief indication is when there is great venous engorgement or 
turgescence. 

In many cases of disease of the mitral valves with ruptured com- 
pensation and marked turgescence of the great veins, venesection 
gives great relief. This also holds true in pneumonia with venous 
turgescence and in uraemia. 

In eclampsia and sunstroke with great cyanosis and venous engorge 
ment, venesection may save life. 

In apoplexy the extravasation of blood into the brain causes great 
arterial tension, and free venesection has been commonly performed 
to relieve this state. Recent studies by dishing, however, indicate that 
bleeding under those conditions is contraindicated. (See Apoplexy.) 

The method by which venesection is practised is yet to be described. 
It is a very simple operation if an assistant is present to make pressure 
on the vein or entire arm. Often this pressure is best exercised by 
means of a handkerchief or bandage tightly twisted about the arm 
above the spot where the incision is to be made. Under these circum- 
stances the veins of the arm become prominent and distended, and 
one of them may be readily bared by a short longitudinal incision of 



638 REMEDIAL MEASURES OTHER THAN DRUGS. 

half an inch, the fascia being separated until the glistening blue sur- 
face of the vessel appears free from fat or connective tissue. Into 
this vessel, with the edge of the knife turned upward, a small longi- 
tudinal incision is made, care being taken that the point of the blade 
is not driven in far enough to injure the posterior wall of the vein, or a 
sharp-pointed pair of scissors is used and the vessel is snipped on its 
anterior wall. If a clot forms and stops the flow, it must be removed 
by a piece of aseptic gauze, while if the flow is to be stopped, remove 
the bandage above and ligate or apply a compress over the incised vein, 
the compress being held in position by a bandage. Care should 
always be taken that the bandage on the upper part of the arm is not 
so tight as to cut off all blood supply to the arteries of the lower 
part of the limb. Many physicians bleed by pushing a large hollow 
needle or cannula through the skin into the distended vein toward the 
hand. 



FEEDING THE SICK 



In the opening pages of this work the importance of properly feed- 
ing the sick has already been emphasized. It is manifestly impossible 
for the writer to go into details concerning the deep and difficult prob- 
lems of the changes in the food when taken into the body for assimila- 
tion. At this point it is necessary only to recall that the foods taken 
by man consist in proteids, carbohydrates, and hydrocarbons. In the 
albuminous or proteid articles of food nitrogen is a prominent con- 
stituent, and the type is egg-albumin. While most nitrogenous foods 
are animal in source, it must not be forgotten that gluten and legumen 
are nitrogenous and derived from vegetables. The carbohydrates 
consist of substances in which carbon, hydrogen, and oxygen are com- 
bined, the hydrogen and the oxygen in the proportion to form water, 
of which the types are starch, dextrin, cane-sugar, grape-sugar, lactose 
or milk-sugar. The hydrocarbons are composed of carbon, hydrogen, 
and oxygen, but the proportion of oxygen is insufficient to convert' 
all the hydrogen into water. The types of this group are butter and 
other fats. 

The function of the proteid, or albuminous, foods is to contribute to 
the repair and formation of the body tissues, particularly those which 
are nitrogenous; they also contribute to the development of muscular 
and nervous energy and the production of heat, being split up into 
nitrogenous and non-nitrogenous parts, from the last of which fat 
may be formed and deposited or burnt up in the development of force. 

The carbohydrates are split up in the body into carbonic acid and 
water, and in this process yield heat and energy. Unlike the proteids, 
they do not enter the tissues of the body unless it be that they are con- 
verted into fat. By reason of the heat and energy which they con- 
tribute to the economy they protect the albumins and fats from demands 
which would otherwise be made upon them for these purposes. 

The hydrocarbons, or fats, are employed in the body to yield force 
and heat, and are stored up in the form of fat, so as to act as a reserve 
in case of need, so that by their use the albuminous portions of the 
body are saved from demands upon them. For these reasons hydro- 
carbons and carbohydrates can be well taken in large quantities by 
those who take much exercise, but are harmful if partaken of largely 
by persons leading sedentary lives. 

It is manifest, therefore, that for the maintenance of health we must 
provide a patient, not with nitrogenous or carbohydrate foods alone, 
but with some of all the food articles, regulating the proportions of 
(639) 



640 FEEDING THE SICK 

each to his needs and his ability to utilize them after they are ingested. 
The practical application of these facts is as follows: 

In fevers, in which there is an active wasting of the tissues of the 
body, we give albuminous foods to replace the tissues destroyed or to 
make up for their loss, and these consist of broths, soups, eggs, milk, 
and the gelatinous substances which, while not very nutritive, are 
what are known as "albumin-sparing" substances. As the secretion 
of the gastric juice is faulty in nearly all fevers, it is important to give 
these foods in semiliquid or liquid form, so that they can be readily 
digested, and we often aid their digestion by the use of pepsin and 
hydrochloric acid. 

As carbohydrates and hydrocarbons add heat or energy to the 
body, and in their combustion protect the albuminous tissues, they 
also must be used, particularly the former. There is no doubt that 
physicians are far too prone to limit the patient's diet to proteids, and 
in the author's practice he invariably prescribes, in addition to the 
proteid foods, thin preparations of starch, such as strained rice, strained 
oatmeal, cracked wheat, and barley, aiding their digestion, if need be, 
with taka-diastase or pancreatin. 

In order that an approximate idea of the proportion of food-stuffs 
may be conveyed to the reader, it may be pointed out that the 
healthy human body must be provided in twenty-four hours with that 
amount of food which will yield his body 3000 calories. 1 This is best 
accomplished by the use of the following proportions, according to 
Egleston: carbohydrates, 400 Gra.; fats, 150 Gra.; proteids, 150 Gm. 
Nearly all food-stuffs contain the several classes of proteids, carbo- 
hydrates, and hydrocarbon in varying proportions. It is interesting 
to note how many more calories are provided by the carbohydrates 
and fats than by the proteids, but it is also worthy of note that the 
proteids provide the materials which are useful for the repair and 
growth of tissue. 

The common foods may be measured approximately as follows: 

Grams. Calories. 

1 tablespoonful of oatmeal, equals 40 34 

1 medium-sized white potato, equals ....... 90 90 

1 slice of bread \ inch 5x5, equals 25 80 

1 roll, equals 30 115 

1 large tablespoonful cf rice, equals 30 45 

1 tablespoonful of macaroni, equals 35 25 

1 tablespoonful of cooked peas, equals 30 40 

1 tablespoonful of sugar, equals 8 33 

1 medium-sized oyster, equals 15 18 

1 orange (small), equals 150 60 

1 egg, equals 50 70 

1 pat or ball of butter, equals 8 80 

1 slice lean roast beef \ inch 5x3, equals 60 70 

1 wineglass of whisky, equals 30 85 

1 A calorie is the French unit of heat, or that amount of heat required to raise the tem- 
perature of one kilogram of water one degree Centigrade. 





Approximate 


Approximate 


Approximate 




Carbohydrate. 


Protein. 


Fat. 


i lories. 


Grams. 


Grams. 


Grams. 


210 


48 


7 




160 


12 


7 




140 




13 


5 


160 






16 


160 


26 






66 


16 






896 calories. 







FEEDING THE SICK. 641 

As pointed out the normal intake when the patient is active or 
febrile is about 3000 calories, and the nutritional balance is approxi- 
mately maintained by 500 grams of carbohydrate, 150 grams of 
fat and 150 grams of protein. The approximate amounts of foods 
needed in health can be calculated from this table: 

Thus a breakfast of : 



6 tablespoonfuls of oatmeal, equals 

1 glass of milk, equals .... 

2 eggs, equals 

2 pats of butter, equals .... 

2 slices of bread 160 

2 teaspoonfuls of sugar, equals 



The other meals can easily be figured in the same mariner. A 
strict milk diet is impossible without starvation because to get 3000 
calories the patient would have to take between 4 and 5 quarts a day. 
This would overburden his stomach and kidneys and, while giving 
3000 calories, would contain an excess of protein and fat and an 
inadequate amount of carbohydrate. As this amount cannot be taken 
the patient must to some extent live on himself. If he attempts this 
excess of milk and his kidneys are diseased he is unable to get rid of 
such an excess of liquid and will become dropsical unless freely purged. 

Water forms such an important part of the body that its free inges- 
tion is advisable, if it is pure, in nearly all cases of disease. 

Having considered the general theory of feeding, we may now pro- 
ceed to the actual preparation of food for the sick. There are several 
important general facts to be borne in mind in this connection : 

1. The food, when prepared, must be capable of ready assimilation. 

2. It must be, as a rule, fairly concentrated in the sense of contain- 
ing great nutritive power in little bulk, since it is a mistake to weary 
a feeble patient with much swallowing. 

3. It must be easily swallowed. 

4. It must be as attractive to the sight, smell, and taste as possible. 
When milk is given for any length of time its taste should be varied, 

if possible, by the addition of enough coffee, tea, cocoa, or sweetening 
to prevent the patient from taking a dislike to it. Its nutritive prop- 
erties may often be advantageously increased by the addition of some 
of the well-known infant foods; and if it curdles too quickly in the 
stomach, this may be delayed by the use of barley-water in equal 
parts, or lime-water, or by the addition of thin oatmeal gruel or strained 
rice to the milk. Often the addition of salt improves the taste and 
aids its digestion, and its dilution by adding aerated or carbonated 
water from a siphon is also refreshing and aids digestion in some 
instances. In other instances the best results are produced by pep- 
tonizing the milk (see below). When broths are used, they may well 
41 



642 FEEDING THE SICK. 

be flavored with other things than the meat from which they are 
made. This is easily accomplished by placing in a small bag such 
vegetables as carrot, turnip, celery, parsnip, parsley, thyme, etc., and 
then cooking this bag and its contents with the broth, whereby the 
nutritive properties of the meat and vegetables and the flavoring of 
the latter are given to the soup. 

The following recipes will be found useful in many cases : 

CASEIN MILK. 

This preparation is useful in feeding adults and infants with very 
feeble or disordered digestion. To one quart of fresh milk at 100° F. 
add four teaspoonfuls of essence of pepsin and mix thoroughly. After 
this mixture has stood at 100° F. until it has become curdled (this usually 
occurs in about thirty minutes), filter off the whey through a clean linen 
handkerchief and allow the curd in the handkerchief to remain suspended 
until the whey ceases to drop from it. The curd is then placed on a 
fine sieve, through which it is pressed by means of a knife-blade or 
spoon. Add to this curd, which has been finely divided by passing 
through the sieve, one pint of water and one pint of buttermilk, which 
should be less than twenty-four hours old. This preparation is practi- 
cally a form of predigested milk and the individual curds are so fine as 
to be easily digested. Depending upon the richness of the milk, one 
quart of this preparation contains a little less than 400 calories, and 
equals about 3 per cent, of proteid, 2.5 per cent, of fat, 1.5 of sugar, 
and 0.5 per cent, of salts. When used in cholera infantum the quan- 
tities administered should, at first, be very small and gradually in- 
creased until the stomach and bowels become tolerant. 



BUTTERMILK AND STARCH. 

Take one quart of fresh buttermilk and add it gradually to one or 
two tablespoonsful of rice flour or wheat flour, stirring constantly so 
as to prevent the formation of lumps. This mixture is now heated 
slowly for a period of fifteen or twenty minutes until it reaches the 
boiling-point, when it is taken from the fire and from one to two ounces 
of sugar are added. It is then placed in a bottle which is hermetically 
sealed, and placed on ice where it may be preserved for a considerable 
period of time. By the use of sugar the deficiency in heat units caused 
by the abstraction of the butter-fat is compensated and the addition 
of the rice flour not only increases the heat units but also prevents 
the formation of tough curds. Such a preparation after standing 
separates into two layers, the upper one being composed of the milk 
serum, and the lower one, containing the coagulated casein in very fine 
curds, which are, therefore, ready for digestion. The bottle should 
be shaken to mix these two layers before its contents are used. Such 
a preparation may be given to infants in the proportion of 3 to 6 ounces 
for each 3 pounds of the child's body weight per day. Where gastro- 



PEPTONIZED MILK. 643 

intestinal disturbance already exists with a passage of undigested 
curds, the buttermilk should be preceded for one or two days by beef 
juice or rice water and then given in gradually increasing quantities. 
This form of buttermilk may also be given to invalid adults as a con- 
centrated, easily digested food. 

As much of the buttermilk which is found on the market is not 
fresh, it is often best to prepare it by the use of " Lactone Tablets," 
which contain lactic acid bacilli. The advantage of buttermilk pre- 
pared by this means is that it contains all its butter-fats, and, there- 
fore, has a higher nutritive value than ordinary commercial buttermilk. 
It is essential, however, that the milk shall be fresh and that no 
preservatives, such as formaldehyde, shall have been used, since such 
preservatives prevent the lactic acid bacillus in the tablets from acting 
upon the casein. 

The method of employing lactone tablets is as follows : 

To one quart of fresh milk add one lactone tablet, shaking or stirring 
the fluid so that the crumbled tablet will be thoroughly dissolved. 
After being properly covered the bottle containing the milk should 
stand at the ordinary room temperature of from 70 to 80 degrees for 
from twelve to twenty-four hours. The warmer the air the shorter 
the time necessary for the change to take place. The bottle containing 
the milk is then placed in a refrigerator for future use. After standing 
for some time it separates into two layers which should be thoroughly 
stirred until a homogeneous fluid is produced before it is used. 

When buttermilk is used not only as a form of food, but also for the 
purpose of getting the effect of the lactic acid bacillus as a therapeutic 
agent, it must be taken when it is not more than twenty-four hours old, 
so as to avoid excessive acidity and in order to obtain active bacilli. 
(See Lactic Acid Bacillus, Part II.) 

PEPTONIZED MILK. 

Take a perfectly clean, clear glass quart bottle and place in it one 
of Parke, Davis & Co.'s peptonizing tablets, or the contents of one 
of Fairchikrs peptonizing tubes, and a teacupful of cold water, and 
after shaking pour into the bottle a pint of perfectly fresh, cool milk 
and stir the mixture thoroughly. Next place the bottle containing 
the milk in a can of water at such a temperature that the whole hand 
may be submerged in it without pain. If complete digestion of the 
milk is deseed, this application of heat may be continued as long 
as twenty minutes, but in most cases five minutes are sufficient. If 
carried on longer than five minutes, the milk will become bitter and dis- 
agreeable to the taste through the development of peptone in excess, 

Immediately after taking the bottle from the hot water it should 
be placed on ice, in order to check further peptonizing and to keep 
the milk from spoiling; or if ice is not available the water-bath should 
be quickly brought to a boil in order to prevent further action of the 



644 FEEDING THE SICK. 

ferment, and the bottle corked and then be put in a cool place. This 
recipe may be used where it is thought necessary to digest the milk 
before it is swallowed. Where we desire simply to aid digestion it 
is best to follow the directions already given, except that the bottle 
is not heated, but at once placed upon ice and allowed to remain 
there, being slightly warmed when it is desired to give it to a child, 
or it may be given as a cool and refreshing drink to an adult, the 
heat of the body rapidly causing the ferment to do its work as soon 
as the food enters the stomach. When irritability of the stomach 
exists in adults, this peptonized milk may be made more agreeable to 
the taste by following the directions given in the first recipe, except 
that it must remain in the hot water for no less than two hours, when 
it is poure I out into a tin cup or pan and rapidly brought to the boil- 
ing point. After this it is strained through a piece of coarse muslin 
anu placed upon ice. Before giving it to a patient this mixture may 
be flavored with lemon- or orange-juice or any form of acid that is 
desired, without the milk becoming curdled. Peptonized milk-punch 
is made from milk prepared in the way already aescribed in the first 
recipe by adding St. Croix or Jamaica rum or brandy, and is a pleas- 
ant nutrient, particularly if the surface of the liquid is sprinkled with 
a little grated nutmeg. 

A very refreshing and agreeable drink may be made by diluting 
peptonized milk one-half with highly charged carbonic-acid water, 
and swallowing it while effervescing. 

WHOLE MILK FEEDING FOR INFANTS. 

In cases in which it is difficult or impossible to arrange for percentage 
feeding of infants, whole milk feeding is resorted to. It is rarely 
begun before the first month of life. If it is needed earlier, the milk 
is to be diluted with water one-half. At first 2 grains of sodium citrate 
to each ounce of milk is used and later 1 grain. Infants often thrive 
remarkably well on this plan. (See Sodium Citrate.) 

PEPTONIZED BEEF. 

The following method of preparing peptonized beef is recom- 
mended by the Fairchilds, and is very useful, as is also peptonized 
oyster stew, as first introduced by the late Dr. N. A. Randolph. 
* Take \ pound of finely minced raw lean beef; cold water, \ pint. 
Mix in a saucepan. Cook over a gentle fire, stirring constantly until 
it has boiled a few minutes. Then pour off the liquor for future use, 
beat or rub the meat to a paste, and put it into a clean fruit-jar with 
\ pint of cold water and the liquor poured from the meat, and add 

Extracti pancreatis 20 grains (1.3). 

Sodii bicarb 15 grains (1.0). 

Shake well together, and set aside in a warm place, at about 110° to 
115° F., for three hours, stirring or shaking occasionally; then boil 



PEPTONIZED EN EM AT A. 645 

quickly. The liquid may then be strained or clarified with white of 
egg in the usual manner, and seasoned to taste with salt and pepper. 

In the great majority of cases it is not necessary to strain the pep- 
tonized liquor, for the portion of meat remaining undissolved will 
have been so softened and acted upon by the pancreatic extract that 
it will be in very fine particles and diffused in an almost impalpable 
condition, and is therefore in a form ready for assimilation in the 
body. 

Peptonized Oysters. — Peptonized oysters are prepared by mincing 
six to twelve large oysters, and adding to them, when mixed with a 
moderate amount of their own liquid, 5 grains (0.30) of pancreatin 
or peptonizing powder and 20 grains (1.3) of sodium bicarbonate. 
The cup containing this mixture is now placed in water at 100° F., 
and allowed to remain there from ten to twenty minutes, accord- 
ing to the degree of digestion desired. After this the liquid mass 
is quickly brought to a boil to cook the oysters and stop digestion, 
and served with pepper and salt as required. Any condiment or 
flavoring substance may be used. 

PEPTONIZED ENEMATA. 

Comparatively recent investigations have proved conclusively that 
so-called nutrient enemata aid very Kttle in maintaining nutrition, 
most of the benefit being due to the fact that the fluid part of the 
injection is absorbed but the solids remain in the bowel. 

A very useful nutrient enema may be prepared by following the 
directions given above for peptonizing milk, except that an egg, yolk 
and white, should be beaten up in the milk before the ferment is 
added. The effect of this enema may be increased by the addition 
of a teaspoonful to an ounce of whisky or wine. This should be warm 
when injected into the rectum. 

As the rectum is apt to become irritable if injections are given 
frequently, and particularly if the same mixture is repeated a number 
of times. This can be avoided by resorting to the " drop method" of 
Murphy and the Fowler posture. (See Peritonitis.) It is often well 
to substitute for the formula just given the following recipes: 

Von Leube recommends 5 ounces of scraped meat, chopped very 
fine, and to this are added lj ounces of finely chopped pancreas; 
the whole is suspended in 3 ounces of lukewarm water, and stirred 
f o the consistence of a thick pulp. This makes one injection. Pan- 
creatin or peptonizing tablets can be as well used as the pancreas 
itself. 

Rennie's formula consists of \ pound of lean meat pulled into 
shreds and added to a pint of beef-tea; to this are added 1 drachm 
of fresh pepsin and \ drachm of dilute hydrochloric acid; the mix- 
ture is kept at a temperature of 99° F. for four hours, during which it 
is stirred constantly. If too great heat be employed, the digestive 
process will stop. 



646 FEEDING THE SICK. 

An enema which Bidwell employs is made as follows: milk, 2 
ounces; strong beef -tea, 2 ounces; yolk of egg, 1; pancreatic solution, 
1 drachm. This is to be prepared one hour before use, and to be 
kept at a temperature of 100° F. ; \ to 1 ounce of brandy is added, 
when necessary, immediately before use. 

Greig Smith uses 1 egg beaten up in 6 ounces of milk with 2 or 3 
teaspoonfuls of meat-jelly, or peptones may be added. This is admin- 
istered warm with or without J ounce of brandy every five or six 
hours. 

DIGESTED GRUEL. 

Digested gruel may be made by taking thoroughly boiled hot gruel 
made from oatmeal, barley, wheat, or from arrowroot, to the amount 
of J pint (240 mils.), and adding thereto, while it is hot, § pint (240 
mils.) of fresh, cold milk; to this may now be added the contents of 
one peptonizing tablet or tube, and the mixture allowed to stand in 
moderately hot water or in a warm place for twenty minutes before it 
is placed upon ice. Ten grains (0.65) of takadiastase may be used in 
place of pancreatin. 

KOUMYSS. 

This preparation of milk which is very useful for children and 
adults during convalescence from acute or subacute exhausting dis- 
eases. Even children of three or four years will acquire a liking for it 
if it is not made too sour by continuing the fermentation process 
too long. The liquid is prepared as follows: Add to 1 pint (480 mils.) 
of cool, perfectly fresh milk 2 teaspoonfuls (8.0) of sugar, and place 
it, after shaking thoroughly, in a clean beer or claret bottle. Then add 
\ of a cake of Fleischman's compressed Vienna yeast, and tightly cork 
the bottle, standing it in a warm place or in a water-bath at 99° to 
100 c F. for eight to ten hours. Then place in a cool place or on ice 
and use as needed. It must be remembered that the development of 
carbonic gas is very great in this liquid, and that if an ordinary cork 
is inserted it must be tied in before the heat is applied. Further 
than this, the cork must be pulled very gently or the liquid will spurt 
all over the room. The best thing to use when about to open a bottle 
of koumyss is a "champagne tap," by means of which the liquid may 
be drawn off as needed. 

DIET LIST. 

The following bills of fare are used in the Children's Hospital in 
Philadelphia with good results, are easily prepared, and the directions 
readily carried out by the inexperienced. 



DIET LIST. 647 

Diet in Gastrointestinal Catarrh for a Child of Seven Years. 

Breakfast, 7.30 a.m.: Milk, with iime- water; 4 teaspoonfuls of 
lime-water to each tumblerful of milk. The lightly boiled yolks of 
two eggs, thin slices of well-toasted bread, or stale bread. 

Dinner, 12 M. : A mutton-chop without fat, broiled ; or a slice of roast 
beef or mutton ; occasionally a bowl of meat broth. Stale bread or toast. 

Supper, 7 p.m.: Milk and lime-water. Stale bread or toast, or 
milk toast. 

For drink: Filtered or boiled water. 

Starch foods to be avoided as much as possible. 



Diet for a Child Two Years Old. 

Breakfast, 7.30 a.m.: Milk. The Hghtly boiled yolk of an egg. 
Thin bread and butter (the bread to be one day old). 

Lunch, 11 a.m.: Milk. A thin slice of bread and butter. 

Dinner, 1.30 p.m.: Beef-tea or small piece of minced roast beef or 
mutton devoid of gristle. One well-mashed potato, moistened with 
gravy. Rice and milk. 

Supper, 6 p.m.: Milk. Bread and butter. 

For drink: Boiled or filtered water. 

Diet for a Child One Year Old (Five Meals a Day). 

First meal, 7 a.m.: 2 teaspoonfuls of grated flour-ball (prepared 
as directed below) in J pint of milk. 

Second meal, 10.30 a.m.: \ pint of milk with 4 tablespoonfuls of 
lime-water. 

Third meal, 2 p.m. : The yolk of 1 egg beaten up in 1 teacupful of 
milk. 

Fourth meal, 5.30 p.m.: Same as the first. 

Fifth meal, 11 p.m.: Same as the second. 

Flour-ball is to be made by taking one pound of good flour — unbolted 
if possible— tie it up very tightly in a pudding-bag; put it in a pot of 
boiling water early in the morning, and let it boil until bedtime, then 
take it out and let it dry. In the morning peel off the surface and 
throw away the thin rind of dough, and with a grater grate down the 
hard, dry mass into a powder. To use this, take from 1 to 2 teaspoon- 
fuls of the powder, rub it down until smooth with a tablespoonful of 
cold milk, and add 1 tumblerful of hot milk, stirring it well all the time. 

Diet for a Child from Six to Twelve Months Old (Five Meals a Daij). 

First meal, 7 a.m.: Mellin's food, 1 tablespoonful or flour-ball 
(grated), 1 or 2 teaspoonfuls (prepared as directed above); hot water, 
4 tablespoonfuls; warm milk, enough to make i pint. Dissolve the 
Mellin's food or rub down the grated flour-ball in the hot water by 
stirring, then add the milk; mix thoroughly. 



648 FEEDING THE SICK. 

Second meal, 10.30 a.m., and third meal, 2 p.m.: A breakfastcupful 
of milk with 4 tablespoonfuls of lime-water. 
Fourth meal, 5.30 p.m.: Same as first. 
Fifth meal, 10.30 p.m. : Same as second. 



SOYA BEAN FLOUR FOR INFANT FEEDING. 

Ruhrah has highly recommended the use of soya bean flour for 
children for whom fresh milk cannot be obtained, or when it is of 
questionable quality; or, again, when cow's milk, even when properly 
diluted, disagrees with the patient, as shown by vomiting or diarrhoea. 
This flour is always used in conjunction with barley flour as follows: 

One level tablespoonful of soya flour, 2 level tablespoonfuls of barley 
flour, a pinch of salt, and 1 quart of water are mixed and boiled for 
at least twenty minutes. Afterward fluid lost in boiling is replaced 
by pure water. To this mixture is added condensed milk in propor- 
tions varying from 1 to 16 to 1 to 8, according to the age of the child 
and the digestive state. From 2 to 8 ounces are used at a feeding every 
three hours. In older children the amount of soya flour and barley 
flour may be doubled, but if too much soya flour is used the stools 
become foul, watery, and dark colored. This is also prone to occur if 
barley flour is not employed, even if the amount of soya flour be proper. 

BEEF-TEA. 

Take 1 pound of lean beef and mince it. Put it with its juice into 
an earthen vessel containing a pint of tepid water, and let the whole 
stand for one hour; strain well, squeezing all the juice from the meat. 
Place on a fire, and slowly raise just to the boiling-point, stirring briskly 
all the time. Season with salt and pepper to taste. In admin- 
istering this always be careful to stir up the sediment. 

Or, take 2 pounds of beef without fat or bone, and half a breakfast- 
cupful of cold water; place in ajar in a saucepan of water; simmer 
four hours. 



RESTORATIVE BEEF-ESSENCE (Ringer). 

Take 1 pound of fresh beef free from fat, chop it fine, and pour 
over it 8 ounces of soft water, add 5 or 6 drops of hydrochloric acid 
and 50 or 60 grains of common salt; stir it well, and leave for three 
hours in a cool place. Then pass the fluid through a hair sieve, press- 
ing the meat slightly, and adding gradually toward the end of the 
straining about 2 ounces more of water. The liquid thus obtained is 
of a red color, and possesses the taste of soup. It should be taken cold, 
a teacupful at a time. If preferred warm, it must not be put on the 
fire, but heated in a covered vessel placed in hot water. 



WINE-WHEY. 649 

Should it be undesirable for the patient to take the acid, this soup 
may be made by merely soaking the minced beef in distilled water. 
Or, take 1 pound of beef free from fat and skin, chop it very fine, 
add a little salt, and put it into an earthen jar with a lid, such as is used 
for roasting venison; seal the edges with a thick paste, and place the 
jar in an oven for three or four hours; strain through a coarse sieve. 
Give the patient two or three teaspoonfuls at a time. Or, cut in 
small pieces 1 pound of lean beef from the sirloin or rump, and place it 
in a covered saucepan, with | pint of cold water, by the side of a fire for 
four or five hours; then allow it to simmer gently for two hours, skim 
well, and serve. 

BARLEY-WATER. 

To prepare barley-water, put 2 good-sized teaspoonfuls of washed 
pearl barley with 1 pint of cold water in a saucepan, and boil slowly 
down to two-thirds. Strain. 



Barley-water for Adults. 

Take of finest barley \ pound ; to this add 1 quart of water and boil 
to 1 pint; strain and add 1 quart of boiled milk. To this add 6 ounces 
each of brandy and lime-water; sweeten to taste; flavor with nutmeg 
and rind of lemon rubbed with sugar. This forms a most nourishing 
and palatable drink when kept cold on ice. 

OATMEAL-WATER. 

Add 1 tablespoonful of oatmeal-flour to 1 pint of water and boil 
down to two-thirds of a pint. Strain. To this may be added, as 
additional nourishment, beaten white of egg. 

RICE-WATER. 

Rice-water is made by boiling 2 ounces of clean rice in 2 quarts of 
water for an hour and a half. 



WINE- WHEY. 

Boil 1 pint of fresh milk; while boiling pour in 1 small tumblerful 
of sherry wine (8 tablespoonfuls) ; bring to the boil a second time, 
being careful not to stir it ; as soon as it boils set it aside until the curd 
settles, and pour off the clear whey. 



650 FEEDING THE SICK. 

ALMOND BREAD FOR DIABETICS. 

Take of blanched sweet almonds \ pound; beat them as fine as 
possible in a stone mortar; remove the sugar contained in this meal 
by putting it into a linen bag and steeping it for a quarter of an hour 
in boiling water acidulated with vinegar; mix this paste thoroughly 
with 3 ounces of butter and 2 eggs. Next add the yolks of 3 eggs and 
a little salt, and stir well for some time. Whip up the whites of 3 eggs 
and stir in. Put the dough thus obtained into greased moulds, and 
dry by a slow fire. 

BRAN BREAD FOR DIABETICS. 

Take a sufficient quantity (say 1 quart) of wheat-bran; boil it in 
two successive waters for a quarter of an hour, each time straining it 
through a sieve; then wash it well with cold water (on the sieve) until 
the water runs off perfectly clear; squeeze the bran in a cloth as dry 
as possible, then spread it thinly on a dish and place it in a slow oven; 
if put in at night, let it remain until morning, when, if perfectly dry 
and crisp, it will be fit for grinding. The bran thus prepared must 
be ground in a fine mill and sifted through a wire sieve of such fineness 
as to require the use of a brush to pass it through; that which remains 
in the sieve must be ground again until it becomes quite soft and fineo 
Take of this bran powder 3 ounces (some patients use 4 ounces), the 
other ingredients as follows: 3 new-laid eggs, \\ ounces (or 2 ounces 
if desired) of butter, and about J pint of milk; mix the eggs with a 
little of the milk, and warm the butter with the other portion; then 
stir the whole well together, adding a little nutmeg or ginger or any 
other agreeable spice. Bake in small tins (patty-pans), which must 
be well buttered, in a rather quick oven for about half an hour. The 
cakes, when baked, should be a little thicker than ship biscuit; they 
may be eaten with meat or cheese at breakfast, dinner, and supper; 
at tea they require rather a free allowance of butter, or they may be 
eaten with curd or any of the soft cheeses. 

"It is important that the above directions as to washing and drying 
the bran should be exactly followed, in order that it may be freed 
from starch and rendered more friable. The bran in its common, state 
is soft, and not easily reduced to fine powder. In some seasons of 
the year, or if the cake has not been well prepared, it changes more 
rapidly than is convenient, owing to moisture. This may be prevented 
by placing the cake before a fire for five or ten minutes every day." 



ALMOND MILK. 

Add 1 to 2 ounces of scalded sweet almonds, deprived of their skins, 
to a little hot water and thoroughly rub them into a pulp, adding 
nearly a pint of scalding water while rubbing. Then boil for fifteen 



MULLED WINE. 651 

minutes; strain, and add enough water to make a pint. This may be 
sweetened with sugar if desired, and is excellent for children who cannot 
take milk. 

ARTIFICIAL MILK FOR DIABETICS. 

Williamson has given the following recipe: "To about a pint of 
water placed in a large drinking-pot or tall vessel, about two or three 
tablespoonfuls of fresh cream are added and well mixed. The mixture 
is allowed to stand for twelve to twenty-four hours, when most of the 
fatty matter of the cream floats to the top; it can be skimmed off with 
a teaspoon easily, and on examination it will be found practically free 
from sugar. The milk-sugar remains dissolved in the water. This 
fatty matter thus separated is placed in a glass and mixed with water. 
Then the white of an egg is added and the mixture well stirred. The 
water and white of the egg are added in sufficient quantities to make a 
mixture which has the exact color and consistence of ordinary milk. 
If a little salt and a trace of saccharin be added, a palatable drink is 
obtained which has almost the same taste as milk, and which contains 
a large amount of fatty material and is practically free from milk- 
sugar. With very little practice the right proportions can be easily 
guessed, and, of course, much larger quantities than those mentioned 
can be prepared." 

JUNKET. 

Add from -|- to 1 teaspoonful of Parke, Davis & Co.'s essence of pepsin 
or Fairchild's essence of pepsin to a pint of milk, which should be at 
body-heat. Place the milk in a cool place, and after the curd has 
formed serve cold and flavor with powdered nutmeg or vanilla. If 
there be too great feebleness of digestion to digest the curd, the liquid 
whey may be given, as it contains the salts and soluble albuminoids 
of the milk. 

Junket may be considerably increased in nutritive value if to the 
milk before it is warmed is added an egg which has been thoroughly 
beaten. In place of the egg a tablespoonful of cocoa may be added 
to 2 teaspoonfuls of sugar and rubbed into a paste with a little water. 
This is added to the warm milk, and then the pepsin is added to make 
the junket. 

MULLED WINE. 

Boil some spices — cloves, nutmeg, cinnamon, or mace — in a little 
water, and add as much of this decoction as is necessary to flavor a 
wineglassful of sherry or any other wine. Add sugar to taste, and 
bring the mixture to the boiling-point. If claret is used, it will require 
more sugar than if a less sour wine is employed. The vessel for heating 
the wine should be scrupulously clean. 



652 FEEDING THE SICK. 



WATERED TOAST. 



Brown several pieces of bread, and carefully butter the toast so that 
the butter is equally distributed. Place enough salt over the toast to 
flavor it and add pepper to taste. Finally pour as much boiling water 
on the edges of the crust as is necessary to soak them thoroughly, and 
serve. This is a more agreeable dish than would be imagined, and 
is useful where milk toast is distasteful. 

MALT SOUP. 

Malt soup is a useful food in infants who are suffering from entero- 
colitis or general emaciation and in those with imperfect digestion of 
the fats. This is easily prepared by using Mead's Dry Malt Soup 
which contains maltose and dextrin, 47 per cent.; wheat flour, 
47 per cent.; potassium carbonate, 1 per cent., and moisture 5 per 
cent. For babies under three months of age the following formula 
may be used: 

Whole milk 7 to 10 ounces 

Boiled water 14 to 20 ounces 

Dry malt soup stock 2 rounded table- 
spoonfuls. 

For children over three months: 

Whole milk 12 to 24 ounces 

Boiled water 12 to 24 ounces 

Dry malt soup stock 2 to 4 rounded table- 
spoonfuls. 

In either case mix enough of the milk and water with the dry soup 
stock to make a thin paste. Add the balance and boil for fifteen 
minutes with careful stirring. Do not use a double boiler. For 
children under three months feed 2 to 3 ounces every two hours. 
For children over three months feed 4 to 8 ounces according to age 
and weight every three or four hours. 

In considering this subject scientifically there are several facts to 
be understood. Starch and dextrine, the first step in starch digestion, 
are polysaccharides and as such are not utilizable until by the action of 
enzymes they are converted first into a disaccharide such as maltose 
and then one step further by enzymes in the digestive tube, or in the 
blood, into a monosaccharide glucose. When cane-sugar, a disac- 
charide, is taken it is inverted into two monosaccharides, glucose and 
fructose, and if milk-sugar or lactose, also a dissaccharide, is ingested 
it must be split by acids or enzymes into the monosaccharides glu- 
cose and galactose. Therefore the use of maltose, cane-sugar or milk- 
sugar is equivalent to employing starch already partly changed to a 
form in which it can be used by the body, but it has been proved that 
the body of a child finds it twice as easy to take up maltose as to 



MALT SOUP. 653 

assimilate either lactose or cane-sugar, although all these are disac- 
charides. The very readiness with which maltose is taken up is on 
the one hand advantageous and on the other disadvantageous. Little 
difficulty is experienced in its assimilation, but the very readiness of 
its absorption tends to flood the body with it before it can be changed 
into glucose and utilized or stored. Commercial maltose containing 
dextrine is therefore not to be condemned because of the presence of 
the dextrine for it retards maltose absorption to some extent and, as 
it has to be changed into a monosaccharide, it is taken up slowly and 
acts as an adjuvant to maltose. It is as if a predigested food were 
taken before bread, thereby giving immediate energy, to be followed by 
a gradual supply from the slowly converted bread to maintain energy. 
The readily obtained energy from the maltose also provides energy 
to aid the body in converting the dextrine into maltose. Finally 
the starch present is changed to maltose so that the stomach receives 
one feeding but the tissues three feedings as conversion and assimila- 
tion go on. 

Malt soup may be also made from the Extract of Malt official in 
the U. S. P., or by using the Malt Soup Extract made by the Mai tine 
Company. The ingredients in the preparation are varied to the needs 
of the individual, but a standard formula may be prepared as follows: 

Mixture No. 1. 

Malt soup extract 2\ fluidounces. 

Sterile warm water . ". 22 fluidounces. 

• Thoroughly dissolve. 

Mixture No. 2. 

Wheat flour . . . ."*- 2 \ ounces. 

Fresh milk . . 11 fluidounces. 

Mix thoroughly and strain through a fine sieve. 

These mixtures are now mixed together thoroughly and are boiled 
for three minutes with constant stirring. After rapid cooling pour 
into sterile feeding bottles and store in a cool place, the bottles being 
plugged with sterile cotton. 

This mixture has a value of about 696 calories and as it is generally 
recognized that an infant requires approximately 45 calories to the 
pound in twenty-four hours the quantity of this malt soup and its 
dilution required by the child may be estimated with fair accuracy. 



PAET IV. 

DIS-EASES. 



ABORTION. 



The treatment of abortion divides itself into three parts: the first 
for its prevention, the second for its arrest when threatened, the third 
for its proper care when inevitable. 

In the preventive means we find, as in nearly every branch of 
medicine, that the use of hygienic measures is more important than 
the employment of drugs. If previous abortions are known to be due 
to syphilis, high blood-pressure, endometritis, or uterine displacements, 
these conditions must be relieved by the proper remedies. If there 
exists no apparent cause for the interruption of normal gestation, 
the patient should use a simple diet, lead a quiet life, avoid sexual 
intercourse, sleep on a hard bed, and resort only to gentle exercise. 
Fresh air is, however, a necessity, and should be plentifully supplied. 
The food should be light, but nutritious and palatable, and a sufficient 
variety supplied to avoid any repugnance to a given dish. In many 
cases abortion is due to deficient nutrition of the foetus, either by 
reason of faulty assimilation on the part of the mother or because of 
poor food, so that if anaemia, debility, or other impoverished states 
of the maternal system be present, these should be treated at once. 
The clothing should be loose, the night's sleep undisturbed and of 
full length, and the mind be set at rest as far as possible in respect 
to household and other worries, and particularly diverted from the 
thought of possible uterine disturbance. 

The use of drugs is to be limited strictly to the fulfilment of a dis- 
tinct indication, and the employment of cathartics is to be avoided, 
the bowels being kept in order by fresh fruits in moderate quantity 
or by mild laxatives, such as cascara sagrada in small doses and 
phenolphthalein. If these fail, rhubarb may be resorted to and 
castor oil in capsule may be used. Podophyllin, senna in full doses, 
saline purges in active amounts, and aloes are not to be used if 
they can be avoided. If the woman be exceedingly stout and ple- 
thoric, saline purges are indicated to act as depletants. It is hardly 
necessary to add that elaterium and scammony or jalap are not safe, 
and can only be used if dropsy and ascites are present, and when we 
must choose the least of two evils. Strychnine, which stimulates the 

(655) 



656 DISEASES 

spinal cord, should never be employed, and cantharides, oil of erigeron, 
and manganese ought not to be used unless they are for some reason 
very necessary. Although quinine is not f itself an abortifacient, it 
is unsafe in very large doses if an abortive tendency is present, and can 
only be used as a prophylactic in cases in which abortion is brought 
about by malarial infection. 

The only drug which seems to be of any service as a prophylactic 
to be taken all through pregnancy is the fluidextract of viburnum 
prunifolium, the dose of which is J to 1 drachm (2.0-4.0). This drug 
is said to be a uterine sedative and to have no injurious effect upon the 
mother or child. 

The arrest of threatened abortion is one of the most difficult duties 
which come to the physician, and there is no doubt that large doses 
of morphine or opium are the best means of quieting the uterus. 
While viburnum prunifolium may be resorted to, we do not know 
enough of it to rest assured of its value, but it should be tried if opium 
is not at hand or fails. The patient should be at once placed in bed 
in the most comfortable position, be so covered as to prevent over- 
heating or taking cold, and receive by the hypodermic needle \ grain 
(0.015) of morphine, or, better still, a rectal injection )f warm starch- 
water containing 45 minims (3.0) of laudanum. The bulk of the 
injection should be small in order not to disturb the bowels, and must 
be at the body temperature. If this is not done, a suppository of the 
aqueous extract of opium, containing \ to \ grain (0.015-0.03), should 
be used. Ice-cold drinks should be given, and no tea or coffee allowed. 
This treatment quiets the uterus, allays nervousness and restlessness, 
and at least puts off the abortion for a few hours. Venesection has 
been practised in very plethoric women with advantage. 

When an abortion is inevitable, it is to be treated by measures directed 
to the avoidance of hemorrhage, the thorough delivery of the ovum 
and its appendages, and the prevention of inflammation and septi- 
caemia. The latter acciden is to be prevented by the most rigid asepsis 
of the patient and physician. For the prevention of hemorrhage a 
number of balls of aseptic absorbent cotton tightly wound with thread 
to the size of a small egg should be packed into the vagina back of 
and around the cervix until the bleeding is controlled, and, while a 
small amount of iodoform may be dusted over them before they are 
inserted, no astringents are to be applied, unless it be tannic acid to 
coagulate the blood in the cotton, as astringents cannot reach the 
bleeding spot. Sponges ought never to be used, as they often fail to 
control the bleeding and rapidly become septic. By means of this 
packing the blood in the uterus cannot escape, and as the uterine walls 
contract they urge the liquid between the membranes, thereby causing 
complete separation. After the tampons are applied ergot should be 
used in the dose of a drachm of the fluidextract or a tablespoonful 
or two of the wine, unless the uterine contractions are already active, 
Generallv after twenty-four hours the removal of the tampons will 



ABSCESS 657 

show the ovum to be in the vagina, but if part of it remains in the uterus, 
the following measures should be resorted to: The administration of 
ergot should be stopped unless the hemorrhage is severe, and the 
uterine cavity is to be cleared by the use of the fingers of the attendant, 
who grasps the membranes and draws them away. Only in skilful 
hands the curette may be employed. ' If the cervical canal is too small, 
it must be dilated by dilators. After the membranes are removed the 
tincture of iodine may be applied to the inner surface of the uterus 
as a haemostatic, antiseptic, and alterative; or the uterus may be 
douched with a 2 per cent, solution of creolin in warm water, about a 
quart being used at a low hydrostatic pressure. A pumping syringe 
should not be used. 

The after-treatment consists in the use of small doses of ergot and 
quinine, of vaginal antiseptic irrigation, or even of uterine irrigation, 
if it is needed, and the maintenance of perfect rest for one or two 
weeks, or longer if possible. Ergot ought not to be given if there is 
reason to believe that portions of the membranes or blood-clots are in 
the uterus, as by contraction of the os uteri it may imprison materials 
which then become septic. (See Puerperal Diseases.) If fever arise, 
the uterus should be carefully curetted and the intra-uterine douches 
of creolin continued until the fever disappears. 

ABSCESS. 

The medical treatment of abscess resolves itself into the use of drugs 
to prevent the further formation of pus, to quiet the systemic disturb- 
ance if inflammation be severe, and to support the body if the suppura- 
tion be prolonged or in large amount or if debility exists. The treat- 
ment may also be divided into that suited to acute and that to chronic 
abscess. 

As acute abscess in its early stages is simply a localized inflamma- 
tion with hyperemia and an outpouring of leukocytes, it may often 
be modified by the use of aconite or veratrum in full dose to 
quiet the circulatory excitement and relieve the congestion. This is 
particularly true where the pain is pulsating. At the same time, if 
the swelling is superficial, a poultice, made by moistening bread- 
crumbs with lead-water, should be placed over it, or lead-water may 
be placed on lint and applied in this way. Belladonna ointment 
smeared over th». same area may be of service, and the tincture may 
be used internally if aconite cannot be had. If a gland be involved, 
the needle of a hypodermic syringe may be inserted obliquely into 
its centre and 5 to 10 minims (0.3-0.60) of a 2 per cent, solution of 
phenol injected into the swelling. This method has been found of 
singular efficacy in bubo when pus seems just about to form. It 
is very often curative, but should not be used in a stronger or weaker 
solution than that named. Another useful abortive method for the 
treatment of the early stages of abscess is the application, externally, 
of a strong solution of nitrate of silver, 20 to 40 grains to 1 ounce 
42 



658 DISEASES 

(1.3-2.6 : 30.0) of water, by means of a camel's-hair brush, all over 
the skin covering the area involved, or by the use of the tincture of 
iodine in a similar manner. 

Internally, calx sulphurata, in the dose of -^ grain (0.006) given 
every hour or two, may be used as an abortive, or at least to promote 
arrest and cause absorption. If it becomes evident that pus is going 
to form, then resort must be had to poultices, which by their heat and 
moisture will aid in the formation of pus by favoring the escape of 
leukocytes and by softening the tissues. The best form of poultice for 
this purpose is to use lint which has been saturated with a 1 : 4000 
solution of mercuric chloride, the moisture being retained by a piece 
of rubber dam placed over the lint. If pus forms and fluctuation 
ensues, the abscess should be freely opened, drained, washed out by 
normal salt solution, or bichloride solution 1 : 5000, and dressed 
with antiseptic gauze. If it is tubercular, the abscess may be 
opened in the ordinary manner, and the cavity packed with iodoform 
gauze, or if it cannot be drained in this way it should be drained by 
aspiration, and an ethereal solution of iodoform injected and allowed 
to remain in the abscess-cavity if it is a small one. The opening is 
now closed by a pledget of cotton wet with tincture of benzoin, and an 
antiseptic dressing applied over it. Not more than 20 grains (1.3) of 
iodoform should be so used in the treatment of tubercular abscess, as 
larger amounts have caused poisoning. (See also Bismuth, Part II.) 

A very good treatment for slow abscess is to wash out the cavity 
with a 10-volume solution of peroxide of hydrogen, provided there is 
a free exit for the gas which is given off. 

If the abscess is chronic (cold abscess) and associated with great 
weakness, resort must be had to the internal use of iron in the form 
of the tincture of the chloride, cod-liver oil with hypophosphites, 
quinine as a tonic to prevent hectic fever, and the use of nutritious, 
easily digested food. Alcohol may be used, and should be given with 
milk or in egg-nog. (See Vaccine-Therapy.) 

The following tonic pill or solution is of service: 

1$ — Strychninse sulphatis gr. j (0.06). 

Ferri reducti . . . .. . . . . . gr. x (0.65). 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulse No. xx. 

S. — One t. i. d. after meals. 

Or 

1$ — Tincturse cinchonse compositse, 
Tincturse gentianse compositse, 

Tincturse cardamomi compositse . . aa f Siij (90.0). — M. 
S. — Dessertspoonful (8.0) t. i. d. after meals. 

Having described the means of treatment, it is to be explained how 
these measures act. The aconite quiets the circulation and thereby 
relieves the inflammation, the lead-water acts locally as an astrin- 
gent and sedative, while the belladonna by its action on the blood- 
vessels contracts the dilated capillaries and allays pain. When 
phenol is injected into an enlarged gland, it acts as an anaesthetic, 



ACNE 659 

as an antiseptic, and as an astringent and stimulant. The nitrate 
of silver applications act by constringing the bloodvessels, as local 
sedatives, and as counter-irritants. The iodine applications do like- 
wise, and also exercise an antiseptic influence. The physiological 
action of calx sulphurata is unknown. The object in using the anti- 
septic irrigations is self-evident, and the employment of iodoform in 
tubercular abscess rests upon the studies of Bruns, of Tubingen, and 
many others, who have found by experiment that the use of iodoform 
is fatal to the Bacillus tuberculosis. As large numbers of corpuscles 
are destroyed in the formation of pus, and other sources of vitality 
are sapped by its formation, the use of arsenic and iron to replace 
the loss is necessary, and of cod-liver oil and tonics to increase the 
blood-corpuscles and the ability to assimilate food. 



ACNE. 

This affection occurs in so many forms and arises from such dif- 
ferent causes that a thorough consideration of its treatment cannot be 
here given: suffice it to state that arsenic is a remedy which will often 
aid in the cure and prevent a relapse if used in small doses for a long 
period; that is, 1 to 3 minims (0.06-0.20) of Fowler's solution three 
times a day for a month or two. This is particularly useful if debility 
and anaemia underlie the disease. If the anaemia be marked, the 
proper treatment is that directed to the cure of this condition (see 
Anaemia); if obstinate constipation is present, relief must be obtained 
by saline purges and the bowels kept in order by cascara sagrada or 
some similar drug. If general debility exists, cod-liver oil is of great 
service; or if much pustulation is present, calx sulphurata, in the 
dose of y-Q- to ■§- grain (0.006-0.008), may be used in pill form three 
times a day. In menstrual acne, sulphur may be used internally, in 
the form of the confection of sulphur of the British Pharmacopoeia, 
to open the bowels, and applied as a wash to the face in the following 
form: 

fy— Sulphuris . . 3j (4.0). 

Glycerini f §j (30.0). 

Aquse rosae q. s. ad f oviij (240.0). — M. 

S. — Apply twice or thrice a day. 

Or the following may be used in cases of severe inflamed acne: 

1$ — Sulphuris iodidi gr. xxx (2.0). 

Cerati gj (30.0).— M. 

S. — Apply to the parts night and morning. 

If the skin is very atonic, muddy, and torpid, it should be bathed 
night and morning with hot water and castile soap, or even with the 
tincture of green soap, and well rubbed with a rough towel. After this 
the following salve may be thoroughly applied: 



660 DISEASES 

J$ — Sulphuris praecipitati 3ss (2.0). 

Adipis lanae hydrosi, 

Adipis ■ . . . aa 5ss (16.0).— M. 

S. — Apply as directed. 

If the green soap causes irritation, some bland application should 
follow it, such as simple cerate or the emulsion of the oil of sweet 
almonds. If the pustules be large, they may be incised, a small Bier cup 
applied, and vent given to their contents, the sac being touched with 
a drop of phenol, or a drop of camphor, 3 parts, phenol, 1 part, may 
be employed. (See Phenol.) If induration is great, ichthyol ointment 
of the strength of 20 parts of ichthyol to 100 of lard should be well 
rubbed in, or resorcinol, 10 to 20 grains to the ounce of lard (0.60-1.3 : 
30.0), be applied. Mercurial ointment may also be used to lessen in- 
duration, but several days should elapse between its use and that of 
sulphur, as otherwise a black sulphuret of mercury will be formed and 
stain the skin. 

The diet should be carefully regulated and fatty foods avoided. 

Stains of the skin after an acne pustule has healed may be removed 
by- 

1$ — Aquae hydrogenii dioxidi . . . f 5 j (4.0). 

Adipis lanae hydrosi f3vj (24.0).— M. 

Ft. unguent. 

S. — Apply locally. 

An autogenous vaccine is often very valuable. Indeed, staphylo- 
coccus vaccine has done better in furunculosis than in any other 
use of vaccine therapy. (See Vaccine Therapy.) 

ADENITIS. 

Cervical adenitis is an inflammation of the lymph nodes, usually 
due to tuberculosis. It may also arise from other forms of infection 
by way of the mouth or tonsils. 

If the condition is a simple enlargement, it may be treated by 
applying iodine ointment and lard, half-and-half, night and morning, 
care being taken that the use of the ointment is stopped as soon as 
reddening of the skin appears or if fluctuation develops. If for any 
reason the ointment cannot be used, the tincture of iodine may be 
thoroughly painted over the swelling, but this treatment is less effica- 
cious. The following is a useful application: 

fy- Ichthyolis ' . . f5iv (16.0). 

Adipis benzoinati fgij (60.0).— M. 

S. — Rub gently a small piece of the ointment over the swelling t. i. d. 

Syrup of the iodide of iron, in the dose of 5 to 20 drops (0.30-1.3), 
may be given, and tonics should be used to improve the systemic con- 
dition. A fresh-air life and residence at the seaside is desirable. 
As soon as fluctuation or reddening shows the formation of pus, all 
abortive treatment should be stopped, and a poultice be applied for 



AMBLYOPIA AND AMAUROSIS 661 

twenty-four to forty-eight hours until the swelling is ready for lancing. 
Lancing is better than allowing the abscess to break, as the scar left 
in after years is a mere line instead of a large cicatrix. 

If, after fluctuation threatens, the swelling disappears in part under 
rubbing with an ointment, this indicates not betterment, but that the 
abscess has ruptured into the surrounding tissues and it should be 
incised at once, freely drained, and swabbed out with tincture of iodine. 
The radical operation of removal of the enlarged glands should, if 
possible, wait until the process is localized. Excellent judgment as 
to the time of operation is often required to prevent general infection 
by operation. 

If the pus is found to be tuberculous, and a large number of these 
cases are so infected, or if the swelling persists, the following treatment, 
recommended by Treves and Grunfeld, is of value in selected cases. 

The entire removal of the glands should be effected by dissection 
alone; directors, handles of scalpels, or fingers should be used to 
separate the glands from the surrounding cellular tissue as closely 
from the capsule as a nerve is cleaned in the dissecting-room. When 
sufficient amount of the anterior surface is exposed, a thick thread is 
passed through the gland and drawn gently, when, by continuing the 
dissection, the operator may gradually get to the back of the gland, 
removing portions of the mass at a time. The cavity should be packed 
with iodoform gauze. If a number of glands are grouped their extir- 
pation if done at all, requires great judgment and skill. 

ALCOHOLISM. 

(See Alcohol.) 

ALOPECIA. 

This affection, when due to a parasite, is best treated, according to 
Crocker, by first' pulling out all the loose hairs around the bald spot 
and then painting the affected surface with linimentum cantharidis 
(liquor epispasticus). Three coats of this liquid should be employed, 
and each coat allowed to dry before the next is applied. In other cases 
an ointment of chrysarobin, \ to 1 drachm (2.0-4.0) to the ounce 
(30.0) of lanolin, may be used, but care mus+ be exercised that too 
much staining of the skin and clothes does not result. Another equally 
good application is 2 grains (0.12) of mercury bichloride to 1 drachm 
(4.0) of rectified spirit and 7 drachms (28.0) of oil of turpentine. This 
mixture may be rubbed in with the finger over and around the patch. 
If the patient's skin will stand it, 5 grains (0.3) of the corrosive sub- 
limate may be used in place of 2 grains (0.12). 



AMBLYOPIA AND AMAUROSIS. 

Amblyopia (or dulled vision) and amaurosis (or blindness) usually 
refer to defective sight or its total loss, the result of functional dis- 



662 DISEASES 

turbance of the retina, optic nerve, or visual centres, and unaccom- 
panied by changes in the eye-grounds in the beginning of the disease. 
These terms, however, also include cases of partial or complete blind- 
ness in which optic-nerve atrophy subsequently develops, and are often 
used to describe ocular disorders not limited by the definitions here 
employed. These cases may be gathered into certain groups: 

I. Congenital amblyopias and amblyopias from non-use of the 
eye. In these there is often a high degree of error of refraction, 
usually far-sightedness; the latter is seen when an eye is debarred 
from binocular vision by a squint. In both the treatment consists in 
as perfect a correction of the optical error as possible, and, in case one 
eye alone is involved, the separate exercise of its functions. Congenital 
amblyopias may include incurable defects in the structure of an eye. 

II. Amblyopias the result of (a) general diseases or conditions — 
typhoid fever, the exanthemata, syphilis, scurvy, malaria, influenza, 
etc.; (b) local diseases or conditions — hemorrhoids, hemorrhage, 
pregnancy, disordered menstruation, kidney disease, diabetes, 
migraine, disorders of the nervous system, functional nervous disease, 
etc. 

The remedies indicated by the special cause are to be employed, 
the medicinal agents most usually needed being mercury, iodide of 
potassium, pilocarpine, particularly in ursemic amaurosis, emmena- 
gogues, and tonics, especially hypodermics of strychnine. As local 
measures repeated fly-blisters to the temples, wet and dry cups, and 
the constant electric current are used. The nape of the neck may be 
cauterized. In hysterical cases metallotherapy may be tried. 

III. Amblyopias the result of the action of certain medicinal and 
toxic agents. 

The abuse of alcohol, and particularly of tobacco, produces a form 
of amblyopia characterized by the development of a scotoma or an 
area in the centre of the field of vision in which the appreciation of 
red and green is lost or greatly diminished. Quinine in excess has, 
in a number of instances, been followed by temporary blindness, 
which is usually denominated quinine amaurosis. Methyl alcohol 
by itself or in so-called purified wood alcohol which appears in com- 
merce under the name of Columbian Spirits, Colonial Spirits, Eagle 
Spirits, Manhattan Spirits, etc.; or in the form of adulterated essence 
of ginger or bay rum, even in comparatively small quantities, may 
produce rapid blindness and atrophy of the optic nerve. Of less 
frequent occurrence are the cases of amblyopia produced by the toxic 
action of salicylic acid, lead, silver, mercury, osmic acid, nitrobenzol 
filix mas, thyroid extract, and the vapor of disulphide of carbon. 
Blindness from atrophy of the optic nerves has not infrequently 
followed the administration of atoxyl and of the other arsenates, for 
example, soamin, arsacetin, hectin, orsudin. The harmful action is 
probably due to the aniline in these compounds. In all instances the 
patient must be withdrawn from the influence of the poison; in tobacco 



AMBLYOPIA AND AMAUROSIS. 663 

amblyopia, in its early stages, this is usually sufficient to effect a cure. 
The remedies which have proved of the greatest utility are digitalis, 
inhalations of nitrite of amyl, nitroglycerin, and strychnine. Iodide 
of potassium should be exhibited in chronic cases, and always in 
amblyopias the result of lead poisoning. The constant current has 
also been employed. 

IV. Amblyopias the result of direct or indirect injury or from reflex 
irritations. 

Traumatic amblyopias may follow a blow upon the eye itself or an 
injury of the skull or spinal cord. To carious teeth, intestinal irrita- 
tions, and the presence of parasites a certain number of amblyopias 
have been attributed, but while it is not possible to disprove the asso- 
ciation, such cases must be received with doubt. After the removal 
of the cause strychnine should be exhibited. Modern methods of 
examination have greatly lessened the number of conditions to which 
the older writers applied the words "amblyopia" and "amaurosis:" 
indeed, it is time to dismiss these words from classifications of ocular 
disorders, except in so far as they are synonyms of dimness of vision 
or of loss of vision. 

Optic Neuritis and Optic-nerve Atrophy. 

Optic neuritis (choked disc; papilledema) most frequently depends 
upon diseases of the brain (tumor, abscess) or inflammation of its 
membrane (meningitis). It is also a symptom of numerous disorders 
— suppression of the menses, exposure to cold, rheumatism, anaemia, 
syphilis, uraemia, lead-poisoning, etc. The remedies are those nat- 
urally suggested by the disease or condition which has called it into 
existence. The prognosis depends upon the cause. Mercury, iodide 
and bromide of potassium, the salicylates, pilocarpine, local blood- 
letting, and fly-blisters are the remedies commonly employed. Choked 
disc dependent upon increased intracranial pressure, in its turn due 
to brain tumor, is best treated by decompressive trephining, and if 
the tumor is accessible by removal of the growth. 

Optic-nerve atrophy may be primary, secondary, consecutive (neuritic 
or postpapillitic) or may be due to retinal or choroidal disease, or due 
to various causes already named in connection with the description 
of the effect of toxic agents and traumatisms. Common causes of 
primary atrophy are syphilis, locomotor ataxia, paretic dementia and 
insular sclerosis. 

Treatment — This depends upon the cause. If syphilis is present, 
the usual remedies are indicated; but mercury is useless in advanced 
cases, even in syphilitics. While salvarsan or neosalvarsan exercise 
no detrimental effect on a healthy optic nerve, at one time it was 
maintained that salvarsan exerted an evil influence on tabetic atrophy. 
Recently this contention has been largely set aside and there are now 
a number of observations on record which tend to show that neosal- 



664 DISEASES. 

varsan, if used early and while color perception is still good, represents 
a therapeutic agent of value in the treatment of tabetic atrophy. 
Salvarsanized serum, injected intraspinously (Swift-Ellis method), 
may do good if employed before the degenerative process has begun. 
Strychnine has been much employed administered in full doses, prefer- 
ably by the hypodermic method ; it may be enforced by nitroglycerine 
or inhalation of amyl nitrite. Other remedies, according to the cause, 
are iodide of potassium, nitrate of silver, phosphorus, arsenic, iron, 
santonin, lactate of zinc, hypodermics of antipyrin (Valude), and 
injections of organic liquids, all of doubtful value. Negative galvan- 
ism has been advised, and good results have been reported. Coleman 
especially recommends the sinusoidal current, a binocular electrode 
being placed over the eyes and an oval pad to the nape of the neck. 
The treatment should take place for twenty minutes each day. High- 
frequency currents have been advocated and they should be tried. 
There is no satisfactory evidence that radium and the Rontgen 
rays are useful therapeutic agents in the treatment of optic-nerve 
atrophy. 

AMENORRHEA. 

This condition depends upon so many causes for its existence that 
it must be treated in many different ways. If ordinary anaemia or chlo- 
rosis shows that there is a deficient supply of blood, measures adapted 
to the relief of such a state are required. (See Anaemia.) In amenor- 
rhcea due to constipation saline purges or other laxatives may be used, 
and the best of these purges is aloes. As constipation and anaemia 
are often present simultaneously, a combination of aloes and iron in 
a pill is commonly resorted to. The iron improves the blood, and the 
aloes stimulates and congests the pelvic viscera by bringing the blood 
to the sexual organs. Aloes also seems to increase the assimilation of 
iron in some unknown manner. The following pill is often of service, 
and was especially recommended by Goodell : 

I$— Extracti aloes ............... 5j (4.0).' 

Ferri sulphatis exsiccati . . . . . . . . . oij (8.0). 

Asafcetidae 5iv (16.0). 

Fiant pilulae No. c. 

S„ — From one to three pills three times a day at each period. 

Cimicifuga has been highly recommended in chronic and apparently 
causeless amenorrhcea in the dose of 30 minims (2.0) of the fluid- 
extract at the time for a proper flow to occur. Within the last few 
years the dioxide of manganese, in the dose of 1 to 3 grains (0.06-0.20), 
has come prominently forward as a remedy in simple idiopathic amen- 
orrhcea, and is undoubtedly of service, but it should be taken for at 
least two weeks before the date upon which each menstruation is 
expected to occur. Potassium permanganate is also useful during 
the same period, but it is inferior to the binoxide of manganese in 
the author's experience. See Corpus Luteum Part II. 



ANEMIA. 665 

Apiol, the active principle of parsley, may be given in capsules in 
the dose of 3 to 10 minims (0.20-0.60) in the same manner, and the 
oils of rue, savine, and tansy have also been employed in capsule in 
the dose of 5 drops (0.30) three times a day. 

In all forms of amenorrhcea a hot sitz-bath at the time for the 
expected "period" is of service, more particularly if the patient has 
''caught cold." The bath should be persevered in for several nights, 
and care should be taken to avoid exposure. Often a little mustard 
added to the water will increase the efficacy of this treatment. 

Under the name of " Dewees's Emmenagogue Mixture," first 
devised by Professor Dewees, of Philadelphia, the following formula 
has been largely used in functional and organic amenorrhcea: 

]$ — Tinctime ferri chloridi f oiij (12.0). 

Tincturae cantharidis f oj (-4.0). 

Tincturse guaiaci ammoniati .... f oiss (6.0). 

Tincturse aloes f oss (16.0). 

Syrupi q. s. ad f Svj (180.0).— M. 

S. — Tablespoonful (16.0) three times a day 

ANEMIA. 
It is, unfortunately, only too true that the entire subject of blood- 
making and blood-breaking is as yet very imperfectly understood, but 
many of our therapeutic facts rest on rational ground. Practically 
speaking, the therapeutist recognizes two very important points, the 
causes of which the pathologist must eventually solve — namely, that 
one class of anaemias is due to defective or deficient haemogenesis, and 
another to excessive haemolysis. The former is generally believed to 
form the simple class, and the latter the essential or pernicious class. It 
is in the excessive haemolysis class that we most frequently fail to pro- 
duce good results. More than this, the causes of excessive haemolysis 
are so various that we can further divide them into removable and 
permanent, the removable being represented by the cases in which 
copraemia or auto-intoxication takes place, while the others are repre- 
sented by the true pernicious anaemia, about which we know very 
little, save that most observers find evidence of defective haemogenesis 
and of profound haemolysis in the percentage of iron in the liver, while 
in the dark-colored urine they believe a destructive agent exists which, 
prior to its excretion, has slaughtered many corpuscles. Unfortunately, 
it is at present impossible for us to separate clinically the anaemia of 
defective haemogenesis from that of haemolytic excess, unless we find 
evidence of great corpuscular disintegration in a copious elimination 
of haemoglobin in the urine, or a jaundice evidently hematogenous in 
character, or a large number of defective corpuscles, which would per- 
haps indicate defective haemogenesis rather than that they were scarred 
veterans of a battle with a poison in the liver cells or elsewhere. Post- 
mortem signs often aid us in the differential diagnosis, but this is too 
late to be of any benefit to the patient. 



666 DISEASES. 

There is one point, however, about which there can scarcely be 
any doubt, and that is that in many cases iron is greatly abused, being 
given when there is no indication for it or more frequently given in 
excessive dose. By excessive dose the author refers to as much as 6 to 
10 grains of reduced iron in a day. The amount of iron in the human 
body is very small, and every study made of its absorption and elimina- 
tion after absorption has shown that these processes are very slow. 
Hamburger recovered from the feces nearly all the iron administered, 
and Jacobi proved that even when the iron was injected into the veins 
10 per cent, was at once eliminated by the bowels, liver, and kidneys, 
and the remainder deposited in the liver, spleen, and other tissues in 
the same manner as is any metallic substance. The researches of 
Gottlieb have also been in confirmatory lines. When we consider 
that there is in the human blood only about 39 grains of iron, all told, 
we can see that the use of 12 grains a day in the course of a little over 
three days places a double quantity of the metal in the economy, 
which is not needed, and is either cast out or deposited at any con- 
venient spot, there to lie undisturbed until it can be extruded. 

Much of course, depends upon the cause of the anaemia, but there 
is only one excuse for the use of the large doses of iron just named — 
viz., a condition of the digestive apparatus which results in the forma- 
tion of a sulphide of iron in great quantity, so that only an infinitesimal 
amount escapes into the system. This perhaps explains the empirical 
fact that in some cases of chlorosis or intense anaemia iron has to be 
given in large doses to accomplish good results. 

One of the best studies on this subject is that of Ralph Stockman, 
who has given us a masterly summary of the subject of the absorption 
of iron in chlorosis. In this summary he points out that we have 
three chief theories as to the action of iron in anaemia. The first, the 
absorption theory, is based on the fact that as iron is taken into the 
body with the food, the iron of the haemoglobin must be obtained 
from this source, and therefore that medicinal iron given by the mouth 
must be absorbed. The second theory rests upon the belief that 
iron is not absorbed when given by the mouth in addition to that in 
the food, but simply acts as a stimulant tc the mucous membrane of 
the alimentary canal, therefore increasing the digestion of food and 
so overcoming anaemia by the general improvement coincident upon 
proper nutrition. This theory is of little value, as it has been proved 
that all forms of iron are absorbed. The third theory is that of Bunge — 
namely, that in chlorotic conditions there exists an excess of sulphur or 
sulphuretted hydrogen in the bowel, which changes the iron in the food 
into a sulphide of iron, which Bunge states cannot be absorbed. He 
believes that the inorganic iron which is given as a medicine saves the 
organic iron of the food by combining with the sulphur, and so indirectly 
cures the anaemia by the protection afforded the food-iron. It is 
important to remember that each of these theories has been supported 
by many careful experiments, but it is also well to bear in mind that 



AN AMI A. 667 

the hypotheses and the experiments supporting them may be errone- 
ously based. Thus, we have no right to imagine that the inorganic 
preparations of iron have a stimulating power over the alimentary 
mucous membrane, or, even if they have, that this power is exercised 
in the peculiar line of aiding in the absorption of the organic iron of 
the food. Again, the researches of Hamburger, Damaskin, Gottlieb, 
Miiller, Jacobi, and Socin, which show that after the internal use of 
inorganic iron theie is no increase in the iron in the urine, are value- 
less so far as the conclusions drawn by them are concerned — namely, 
that as there is no increase in iron in the urine, there is none in the 
blood, and therefore it is not absorbed. These conclusions are not 
justified, because they are based on the erroneous views that because 
iron is not in the urine it is not in the blood, and because it is not 
in the blood it is not absorbed. Every one knows that in the case of 
chronic lead-poisoning, when the body is saturated with the metal, 
there is often no lead in the urine, the poison being deposited in the 
tissues; and if this is true of lead, it may be of iron. Particularly is 
this to be remembered when we find Stockman quoting the researches 
of Mayer, Bidder, and Schmidt, and a host of others, who have proved 
that we are not to look to the kidneys as the path for the excretion of 
iron, but to the intestinal walls. Finally, Stockman has proved 
that when iron is used hypodermically it cures anaemia, although it 
cannot under these conditions stimulate the digestion or combine 
with sulphides. 

We learn from practical experience several things which science 
does not tell us — namely: Iron will not cure all cases of anaemia, 
even if they belong to a functional type, but other methods must be 
resorted to at the same time or separately for their cure. Reduced 
iron is the best chalybeate for uncomplicated cases. Besides using 
iron in this form, we should employ laxatives if the bowels are con- 
fined; mineral acids, particularly nitric and nitrohydrochloric, for their 
effect on the function of the small intestine and liver; and in addition, 
bitter tonics of a more or less simple form, according to the exigencies 
of the case, using quinine if malarial infection seems lurking in the body, 
simple bitters if the stomach lacks tone, aromatic bitters if the digestive 
tract seems sluggish from atony of the muscular coats, with a resulting 
formation and accumulation of flatus and lack of digestive juices. 

In many cases of anaemia there exists, either as a cause or effect. 
well-developed intestinal indigestion, and it is thought this results in 
the production of poisons which are responsible for the decrease in 
the corpuscular elements of the blood. The use of laxatives with the 
iron is not only necessary, as already stated, but in addition, to over- 
come this production of toxic products, intestinal antiseptics, such as 
by thymol. (See Thymol.) Tapeworm may also be a cause. 

The preparations of iron best employed in anaemia are the insoluble 
salts just named, such as Quevenne's iron and the carbonate, but there 
are indications for each salt which must be regarded. In many 



668 DISEASES. 

anaemic persons, particularly females, the tongue is broad and white, 
not from coating, but pallor — is flabby and torpid looking. Under 
these circumstances the bowels should be kept moving by mild purges, 
and a bitter tonic like calumba and an acid preparation of iron be 
taken by the patient. In the anaemia caused by rapid childbearing 
and lactation, cod-liver oil, the hypophosphites, and lactophosphates of 
calcium should be used, while iron and quinine in tonic dose may be 
also of service. With some practitioners Blaud's pill is very much 
used, made as follows: 

1^ — Ferri sulphatis exsiccati 

Potassii carbonatis aa 3ij (8.0). 

Syrupi q. s. — M. 

Fiant pilulae No. xlviii. 

S. — One to three pills three times a day, after meals. 

In cases of marked secondary anaemia, in which the broad, flabby 
state of the tongue indicates poor absorbent power of the alimentary 
tract, and in pernicious anaemia, citrate of iron may be given intra- 
muscularly with advantage. It is best given by use of sterile ampoules 
containing about J grain (0.02). (See Iron.) 

Although it is perfectly true that we have almost no knowledge of 
the manner in which alteratives act in instances of disease where, 
through morbid functional activity, enlarged glands or growths appear, 
it is evident that they must act upon the trophic nerves or directly 
upon the nutrition of the affected parts. One thing we do know, 
however, and that is that small doses of most of the so-called alterative 
drugs act as very distinct stimulants to the development of normal 
structures, and in no instance do we find this more typically repre- 
sented than in the effect which they exert upon the blood. A number 
of years ago Keyes, of New York, emphasized the value of minute 
doses of mercury bichloride in syphilitic and other anaemias, and 
abundant clinical observation has certainly confirmed his views. The 
dose of bichloride of mercury in anaemia should be about 4V grain 
(0.0015). Not only will minute doses of the bichloride act in this 
way, but small amounts of calomel or mercury itself will have such 
an effect. 

Inunctions of very small amounts of mercurial ointment once a day 
or every other day, in adults and in children, will increase the fulness 
and redness of the cheeks and lips and the number of the corpuscles, 
the piece of ointment used being no larger than the half of a very small 
pea. This treatment will be found of service in cases not necessarily 
dependent upon specific taint. The marked increase in the nutrition 
of children of a syphilitic taint who are suffering from marasmus under 
the internal use of gray powder and full inunctions of mercurial oint- 
ment is most extraordinary. 

Arsenic is also of value in anaemic conditions, and may be employed 
in relatively larger doses than mercury bichloride. Many clinicians 
have shown the value of this drug in anaemia. Any one of the prepa- 
rations of arsenic may be employed, and should the anaemia be per- 



ANAL FISSURE. 669 

nicious in its type, or should it depend upon leukaemia or pseudo- 
leukemia, the arsenic must be pushed in ascending doses until marked 
evidences of its general effects are manifested. Salvarsan or neosal- 
varsan may be used in some cases of pernicious anaemia, using small 
doses of 0.1 rubbed up with a fatty base and preserved in hermetically 
sealed ampoules ready for hypodermic use. Arsenic is of particular 
merit in those forms of anaemia in which the blood-cells are lacking 
in number rather than in haemoglobin. 

In pernicious anaemia splenectomy and repeated transfusions are 
to be considered and very pronounced, but unfortunately only tem- 
porary good results follow the free use of arsenic by the mouth or 
the hypodermic employment of cacodylate of soda (see Part I). 

Diet is an important part of the treatment of anaemia. The food 
should be good, well flavored, and varied, as well as easy of digestion. 
It should contain, as far as possible, the remedies needed by the 
system, such as bone salts and iron, and its ingestion may be accom- 
panied by some red wine, such as port. 

ANAL FISSURE. 

This is one of the most painful affections to which man is subject, 
and requires intelligent treatment, generally by surgical means if the 
result is to be curative, although great relief can be obtained by the 
use of drugs. 

The most annoying feature of the lesion is the intensity of the pain 
on defecation, which is so severe that emptying of the bowel is post- 
poned as long as possible by the patient. 

To relieve this pain and enable the patient to have a fairly comfort- 
able stool, nothing is so good as an iodoform supository containing 2 
to 10 grains (0.12-0.60) of the drug, preceded by an enema of sweet oil, 
given the night before and retained to soften the feces. Iodoform being 
a local anaesthetic, the passage may take place with very little suffer- 
ing. If much spasm of the sphincter is present, extract of belladanna, 
{ grain (0.015), may be added to each suppository. For the cure of 
the fissure a drop of strong phenol may be applied to the spot, and a 
lotion of tannic acid, glycerin, and water used if hemorrhoids are also 
present. Ringer highly recommends the application to the fissure, 
by means of a brush, of a solution of bromide of potassium, 1 \ drachms 
to 1 ounce (6.0:30.0) of glycerin. In order that the passages may be 
soft and yet the patient not be purged, sulphur may be given in the 
dose of 20 to 40 grains (1.3-2.6) every night, or, if this cannot be used, 
castor oil may be administered. The best way to give the sulphur 
is by combining it with powdered cinnamon or aromatic powder. 
Sometimes relief is obtained by the use of flexible collodion painted over 
the fissure. Pure ichthyol locally applied sometimes does good. 

The radical means of cure consist in stretching the sphincter ani 
under anaesthesia. This is followed by incising the base of the fissure, 
curetting it, and then touching it with a stick of nitrate of silver. 



670 DISEASES. 



ANEURISM. 



The treatment of aneurism by drugs is not very successful, but is 
at least worthy of trial in all cases. Vascular disease resulting in 
such a lesion depends upon so many causes which may modify the 
treatment that the history of the case should be carefully considered. 
The most common causes are traumatism and syphilis, and very 
often injury is superimposed upon systemic infection. Whatever the 
cause of the disease may be, iodide of potassium is par excellence the 
remedy most apt to do good, even if it does not cure. The doses 
should be large, 20 to 30 grains (0.3-2.3) three times a day if the 
patient will bear them, and the prognosis under this treatment is far 
more favorable if the cause be syphilis than if the disease be idiopathic 
or traumatic. 

For successful treatment the recumbent position must be insisted 
upon, the patient being kept quiet in bed, changing his position as 
little as possible and confining himself to the most simple and easily 
digested diet, with entire avoidance of all stimulating substances 
either in the way of food or drink. Often it is best to adhere to an 
absolute milk diet. If the heart is excitable and irregular in its 
action, the vascular system irritable, and a high arterial tension is 
present, the circulation must be qi ieted by small doses of tincture of 
veratrum, say 4 to 8 minims (0.25-0.5) twice or thrice a day, but 
digitalis is not to be employed, since it increases the strain upon the 
aneurismal sac, although it quiets the irregular heart beat. Aconite 
may also be used with care, but it is inferior to veratrum. If the pain 
be very great — and it often is severe, particularly at night — opium is 
indicated, and sleeplessness should be allayed, not by full doses of 
morphine alone, but by morphine and chloral ; or, better still, croton- 
chloral should be so ordered that the patient receives J- grain (0.008) of 
morphine and 10 grains (0.60) of croton-chloral in pill at bed-time. 
All attempts to cure aneurism by the use of other drugs unless syphilis 
indicates mercury, are useless when the lesion is thoracic or abdominal; 
and when it occurs in the extremities, as in popliteal aneurism, pressure 
or surgical measures are to be resorted to as the chief means of cure. 
If dyspnoea is marked in thoracic aneurism, slight inhalations or 
"whiffs" of chloroform are sometimes useful, as is also morphine, 
given hypodermically in the dose of J grain (0.008). 

When a sacculated aneurism develops in the thoracic or abdominal 
aorta and is of good size, the best treatment is the introduction of gold 
wire, and the aiding of clot formation by electrolysis. The operation 
consists in pushing a hollow insulated needle into the sac, and then 
passing through it from 30 to 50 feet of fine gold wire, fed from a spool, 
so that it coils in the cavity. The external end of the wire is attached 
to the positive pole of the battery, and a large clay electrode is attached 
to the negative pole and placed under the back. The current is grad- 
ually turned on and increased, during a period of fifty minutes, from 



PLATE IV 




Showing the manner in which the wire is coiled in an aneurism of 
the ascending arch. The specimen is not only split vertically but cut 
transversely and the anterior wall lifted and turned back. Most of the clot 
has been removed to show the wire. In the centre of the aorta is shown 
the small orifice which opened into the sac. 



PLATE V 




Skiagraph showing Wire Coiled in Aneurismal Sac from a 
Patient in the Author's Wards. 



Case reported by Dr. Beardsley 



ANGINA PECTORIS. 671 

5 to 40 milliamperes. The wire is then cut off, the needle removed, 
and the operation is finished. No accident during the operation has 
been reported when properly performed. It is absolutely contraindi- 
cated in fusiform aneurism. * The first result is relief of pain, usually 
before the operation is completed. The second result is arrest of the 
growth, even when the skin over it seems about to give way. The 
third result is prolongation of life in hopeless cases for weeks or years. 
The writer has performed this operation a large number of times with 
satisfactory results, although when the growth was very large and the 
aorta severely diseased, the inevitably fatal result was postponed a 
comparatively short time, because the sac enlarged in another direc- 
tion and ruptured or caused death by pressure on vital tissues. (See 
Plates IV and V.) 



ANGINA PECTORIS. 

The exact pathological changes existing in angina pectoris are by 
no means clearly understood, but without doubt many attacks are due 
to spasm of the bloodvessels, which results in distention of the left side 
of the heart, which organ is already dilated or enfeebled by disease. 
Often, too, the coronary arteries have undergone degenerative changes, 
thereby increasing the cardiac debility. Remedies which ordinarily 
relieve pain act too slowly or too feebly to be of service in angina pec- 
toris, and even if successful would only relieve the symptom without 
removing the cause. The indication when the blood-pressure is high 
is to relax the vascular spasm, thus relieving the overburdened heart. 
As first pointed out by Brunton, the nitrites possess this power, and to 
him belongs the credit of first applying this class of drugs to this ail- 
ment. All the nitrites are useful, but the nitrite of amyl and nitro- 
glycerin are the best remedies for the attack itself, and the nitrite of 
potassium or sodium for the intervening periods or when the paroxysm 
is prolonged. The reason for this lies in the fact that the sodium and 
potassium compounds are more stable than the other two compounds, 
are more slowly broken up in the body, and therefore more prolonged 
in their effects. In an attack a few drops of the nitrite of amyl should 
be given by inhalation from a handkerchief, or the nitroglycerin can be 
used in the dose of 1 to 2 minims of the official Spiritus glycerylis nitratis 
hypodermically, The dose of the sodium and potassium nitrites is 1 
grain (0.03) five times a day, but all these drugs are useless unless the 
arterial tension is high or the action of the heart labored. 

If vascular relaxation is present, the nitrites should be supplanted 
by stimulants, such as alcohol, in full dose, in warm water. Ether 
given hypodermically is often of service, or Hoffmann's anodyne may 
be used instead of ether by the mouth or hypodermically with good 
results. Digitalone in the dose of half a grain (0.03) may be given 
hypodermically during the attack to stimulate the heart if it is 



672 DISEASES. 

weak, and by the mouth, between the attacks, to improve its con- 
dition. 

If the nitrite does not relieve the pain, or if it cannot be used because 
of some contraindication, morphine must be given hypodermically 
in the dose of \ to J grain (0.015-0.03), but it should never be given 
by the mouth under these circumstances, as its absorption will be too 
slow and its effects will come on after the pain has ceased. 

The prevention of future attacks rests upon the elimination cf all 
causes which can possibly produce a nerve-storm and cardiac irri- 
tability, and in the administration, if the arterial tension is high, of 
nitroglycerin or one of the other nitrites in full dose for long periods of 
time. As a rule, these drugs have to be gradually increased in dose 
in order to maintain their effect. Full doses of one of the iodides, 
particularly Donovan's solution, continued over a long period of time 
are useful. 

The following is a valuable prescription for use between the attacks 
if the heart is feeble and the tension high: 

I*— Tincturae digitalis f 5j (4.0) vel f5iij (12.0). 

Tincturae belladonna* " f§ss (15.0). 

Spiritus glycerylis nitratis TTtxxiv 1.6) vel f 3J (4.0). 

Tincturae cardamomi f5iij (90.0). — M. 

S. — Teaspoonful (4.0) three or four times a day. 

The diet should be moderate and easy of digestion, and salads, 
lobster, and similar articles of food avoided. If the patient is inclined 
to take exercise of a violent character he must be restrained, but, on 
the other hand, some gentle exercise may be permitted if it is possible 
to take it without precipitating an attack. 

Tonics, fresh air, freedom from mental worry, and avoidance of 
exposure to cold are also necessary, and running for a car, or per- 
forming any act calculated to suddenly increase arterial pressure and 
cardiac work, is to be avoided. 

In that form of heart pang occurring in nervous females, some- 
times called pseudo-angina pectoris, 1 drachm (4.0) of ether in ice- water 
or capsules will often abort the attack, or if the paroxysm is caused 
by dyspepsia and if the stomach be overloaded, the sufferer may be 
relieved by an emetic or the stomach-pump. 



ANOREXIA. 

Anorexia, or lack of appetite, is only a symptom of ill health, gen- 
erally associated with debility or other systemic disorder, such as 
anaemia, fever, and many exhausting diseases. It is best treated by 
a well-cooked and daintily prepared diet, the use of the bitter tonics, 
such as gentian, cardamoms, and the mineral acids, or by the use of 
one of the following prescriptions: 



APOPLEXY. 






T$ — Arseni trioxidi 

1$ — Arseni trioxidi 

Extracti nucis vomicae .... 

Quininae sulphatis 

Fiant pilulae No. xx. 

S. — One t. i. d. after meals. 


. gr. \ (0.03). 
. gr. \ (0.03). 
. gr. iv (0.25). 
. gr. xx (1.3).- 


-M 



673 



Or, 

1$ — Acidi hydrochlorici diluti . . . . f oss (16.0). 

Tincturae cinchonse compositae . . . f ovj (180.0). — M. 

S. — Dessertspoonful (8.0) three times a day, after meals, well diluted with 
water. 

(For the use of other bitter tonics see Calumba, Quassia, Chamo- 
mile, Cardamom, and Nux Vomica. None of these drugs is suitable 
if there is any acute irritation or inflammation of the stomach or intes- 
tines.) (See Indigestion.) 

APOPLEXY. 

Up to a recent period it has been held that the high arterial tension 
of apoplexy was evil in its effect because it increased the extravasation 
of blood through the leaking vessel, and for this reason venesection has 
been commonly employed. Studies carried on by Kocher, in Berne, 
and by Cushing, in Baltimore, seem to indicate that this high arterial 
tension is an effort of nature to drive sufficient blood into the cranium 
to maintain the circulation in the brain, which would otherwise be 
impaired by the pressure of the extravasated fluid, for great inter- 
cranial pressure depresses the vasomotor centres and with its failure 
the vital centres nearby fail to receive an adequate supply of blood. 
Some surgeons have advocated opening the cranium and removing 
the clot. The objection to this plan is that the soft tissues of the brain 
have been irreparably damaged by the rushing of the blood from the 
ruptured vessel. The condition is quite different from that found in 
meningeal hemorrhage. 

With our present knowledge it is probably best to use measures 
which are helpful and not radical. 

Hot mustard plasters may be applied to the feet, or a hot mustard 
foot-bath be used if this is practicable. Ice in an ice-bag or wrapped 
in a towel may be applied to the head. If vomiting comes on, care 
must be taken that the stertorous breathing does not draw into the 
lungs particles of the half-ejected food. Sometimes croton oil, 1 
minim (0.05), placed on the tongue with 5 minims (0.3) of sweet oil 
may cause a depletant catharsis which will relieve cerebral engorge- 
ment, or \ grain (0.01) of elaterium may be used. The head must 
be kept high and the feet low. These are the methods to be used 
immediately after the rupture of the bloodvessel. 

The objects to be sought, after the "stroke" has occurred and the 

hemorrhage has ceased, are the removal of the extravasated blood, the 

restoration of function in the paralyzed parts, and the prevention of 

secondary lesions consequent upon inflammation of the brain as a 

43 



674 DISEASES. 

result of the injury to its substance. If the patient survives the attack, 
no drugs should be used for one or two days, until the clot in the 
ruptured vessel has become firmly fixed, unless symptoms of cerebritis 
arise, when vascular sedatives, such as aconite, must be pushed if the 
pulse is tense, and calomel administered in small doses, \ grain (0.015) 
of each every four hours. After the clot has firmly formed and has 
plugged the leak in the bloodvessel, we may proceed to take measures 
for the absorption of the exudate, the chief measures consisting in the 
use of iodide of potassium in as large doses as the patient will bear 
without the production of iodism. This drug should not be resorted 
to until several days, or even two or three weeks, have elapsed after the 
attack. Mercury in small doses may also be given. 

In order that the muscles of the extremities may not waste and 
become powerless from disuse, passive exercise, rubbing, and, if pos- 
sible, massage, must be resorted to. Electricity may be applied to 
them in the form of the slowly interrupted current, and strychnine 
may be used hypodermically or by the mouth as a stimulant to the 
trophic centres in the spinal cord. None of these measures is to be 
employed if any inflammation exists in the brain, as they will increase 
the cerebral disorder, and at least three weeks should elapse after the 
attack before they are resorted to. (See Strychnine.) 

Electricity applied to the head to remove the lesion is useless, as 
the current does not go through the brain, but around the skull by 
means of the scalp. 

A very careful diet is to be maintained. Meats are to be used very 
sparingly, the bowels maintained in perfect regularity, and no wines 
are to be taken nor' any stimulants used lest they cause a second 
rupture of the weakened vessel in the brain. 

Apoplexy must be carefully differentiated from acute alcoholism and 
opium-poisoning, which it much resembles. (See Alcohol.) 

If respiration fails, nothing can be done with much advantage, but 
atropine or strychnine may be given hypodermically. The use of 
electricity to stimulate the phrenic nerve and diaphragm when respi- 
ration fails is a remnant of senseless medical practice, and is partic- 
ularly useless in apoplexy. (See Asphyxia.) 

Above all things, stimulants are contraindicated during the acute 
attack, even though the pulse fails, as they increase the hemorrhage 
into the brain. 

If the symptoms of apoplexy are produced by an embolus or throm- 
bus, bleeding is useless, and it may be harmful by decreasing arterial 
pressure and thereby delaying the establishment of collateral circu- 
lation. 

APPENDICITIS (ACUTE). 

It is to be remembered that many cases which years ago would have 
been called idiopathic peritonitis are now recognized as arising pri- 
marily from inflammation of the appendix vermiformis. For this reason 



APPENDICITIS. 675 

it is incumbent upon every physician who is called to see a case of 
abdominal, or right-sided lower thoracic, pain to examine carefully 
into the condition of the appendix. No routine treatment for appen- 
dicitis can be followed, as each case possesses distinct individuality. 
There are many surgeons, holding extreme views, who assert that the 
mere presence of appendicular inflammation for a few hours renders 
an extirpation of this organ necessary. There is good reason for this 
view because very frequently the diseased organ is removed before it has 
done harm or one is startled at finding on opening the belly that the 
appendix is just about to perforate or rupture or is already gangrenous. 
For these reasons there are doubtless many cases in which the phy- 
sician postpones consulta tion with a surgeon until it is too late to save 
the patient. On the other hand, many cases of acute appendicitis get 
well without operation. (See below). 

It is unnecessary to give a purgative before the operation, since 
the caput coli never contains feces in any quantity, and, furthermore, 
in those fairly severe cases which demand operation at once the 
possibility of perforation of the appendix, with escape of the contents 
of the bowel into the peritoneal cavity, is always to be remembered, 
for if perforation has occurred the purgative may increase the extrava- 
sation of the intestinal contents. 

If the patient shows definite tenderness on pressure over McBurney's 
point, has a quickened pulse-rate with distinct, but not necessarily 
marked, fixation of the abdominal wall on the right side, and has a leu- 
cocytosis of 15,000 to 25,000, even if the temperature is not raised, advise 
operation if a surgeon skilful to do it well and experienced enough to 
meet unexpected complications can be had. If there is a history 
of severe pain followed by relief without the use of opiates, operate, 
because the relief is probably due to gangrene or perforation. 

If the patient has been ill some days and diffuse peritonitis has 
developed, operation is to be postponed until the inflammation sub- 
sides or is localized, and the treatment described under Peritonitis 
instituted. Sometimes it is best to postpone surgical interference in 
mild cases until after the acute attack is over, but the difficulty lies 
in the fact that sometimes cases presenting mild symptoms are actually 
severe and slough early. Even if the symptoms are mild, if there is 
a history of other attacks it is best to operate. 

In all cases of appendicitis in which operation is refused or in which 
it is not possible to get the aid of a competent surgeon, the method to 
be followed is briefly as follows: The patient is to be put to bed 
and absolute rest on the back insisted upon. He must not rise to 
the sitting posture even for defecation or urination. No food or 
drink should be given for twenty-four or thirty-six hours, in order 
that the greatest degree of intestinal rest may be attained. If con- 
stipation has been present so that the bowels are loaded with feces, 
it is best to unload the colon by rectal injections. After the bowels 
have been moved, sufficiently large doses of opium or morphine are to 



676 DISEASES. 

be given to relieve pain if it is severe enough to be agonizing. The doses 
should be so small as to only "take the edge off the pain," but they 
must not stupefy the patient, so that he fails to give clear answers to 
questions. Proctoclysis may be resorted to. (See Peritonitis.) 

The whole question as to operation depends upon the severity of 
the inflammatory process, the medical attendant's ability to determine 
its severity, the state of the patient (see Peritonitis) and not least, 
upon the ability to obtain first-rate surgical skill in the operator. 
Richardson believes that if the operator is inexperienced the patient's 
chances are best from medical treatment. 

In this connection it is of interest to consider the plan instituted by 
Ochsner, and which has given results which demand attention. The 
determination of the character of the treatment to be carried out rests 
upon the condition of the appendix at the time the patient is seen. 

His views are best described as follows : 

1. Patients suffering from chronic recurrent appendicitis should be 
operated on during the interval. 

2. Patients suffering from acute appendicitis should be operated on 
as soon as the diagnosis is made, provided they come under treat- 
ment while the infectious material is still confined to the appendix, if a 
competent surgeon is available. 

3. In all cases of acute appendicitis without regard to the treatment 
contemplated the administration of food and cathartics by mouth should 
be absolutely prohibited and large enemata should never be given. 

4. In case of nausea or vomiting or gaseous distention of the abdo- 
men, gastric lavage should be employed. 

5. In cases coming under treatment after the infection has extended 
beyond the tissues of the appendix, especially in the presence of begin- 
ning diffuse peritonitis, conclusions 3 and 4 should always be followed 
until the patient's condition makes operative interference safe. 

6. In case no operation is performed, neither nourishment nor 
cathartics should be given by mouth until the patient has been free 
from pain and otherwise normal for at least four days. 

7. During the beginning of this treatment not even water should be 
given by mouth, the thirst being quenched by rinsing the mouth with 
cold water and by the use of small enemata. Later small sips of very 
hot water, frequently repeated, may be given, and still later small sips 
of cold water. There is danger in giving water too freely, and there is 
great danger in the use of large enemata. 

8. All practitioners of medicine and surgery, as well as the general 
public, should be impressed with the importance of prohibiting the 
use of cathartics and food by mouth, as well as the use of large enemata, 
in cases suffering from acute appendicitis. 

9. It should constantly be borne in mind that even the slightest 
amount of liquid food of any kind given by mouth may give rise to 
dangerous peristalsis. 

10. The most convenient form of rectal feeding consists in the use 



ASPHYXIA. 



677 



of one ounce of one of the various concentrated liquid predigested 
foods, dissolved in three ounces of warm normal salt solution "intro- 
duced slowly through a soft catheter inserted into the rectum a dis- 
tance of two or three inches. 

11. This form of treatment cannot supplant the operative treatment 
of acute appendicitis, but it can and should be used to reduce the mor- 
tality by changing the class of cases in which the mortality is greatest 
into another class in w T hich the mortality is very small after operation. 

To this plan the author would add the use of normal saline solution 
by hypodermoclysis, with the object of allaying thirst and flushing the 
kidneys. (See Enteroclysis in article on Peritonitis, Important.) 

ASPHYXIA. 

When practising artificial respiration in cases of asphyxia the 
so-called "prone-posture method" of Schafer or Sylvester's method 
should always be employed. 



Fig. 120, 




Artificial respiration by Sehafer's method. By this means fluids and mucus are more readily 
txpelled from the upper respiratory tract than in the older methods. 

Sehafer's method consists in placing the patient so that he lies on 
the anterior aspect of the body, with the face turned to one side. 
The physician then kneels at one side or astride of the patient and, 
placing his hands on the floating ribs, so that the heel of the hand rests 
at about the posterior axillary line, presses upon the thoracic walls, 
which drives out the air from the chest and also any fluid or mucus 
which may be blocking the upper respiratory passages. The pressure 
is then removed and the natural elasticity of the chest wall causes 
inspiration. The movements should be made about fourteen times 
a minute. 

Sylvester's method consists of laying the patient on some hard, 



678 DISEASES. 



flat surface, kneeling above his head, and then, after grasping the 
arms at the elbows, bringing them upward and outward, so that they 
follow the plane on which the body is extended. This movement 
causes expansion of the chest, or inspiration. After a moment's pause 
the arms are lifted up and brought toward one another, and then 





Fig. 121. 




i 


v 

• 


# 



Sylvester's method of artificial respiration. First movement : the patient's arms are placed at 
right angles to the trunk, the elbows resting on the floor, to expand or inflate the chest. 

while still approximated, pushed down near to their original position 
upon the floating ribs, upon which they are pressed. This last move- 

Fig. 122. 




Sylvester's method of artificial respiration. Second movement : the patient's arms are drawn 
toward the physician, in order to expand the chest still further. 

ment drives out the air from the chest, or causes expiration. These 
movements should be at the rate of from sixteen to twenty per minute, 
about that of normal respiration, and be persisted in for at least forty- 
five minutes, even though the case seems hopeless, as cases have 



Asphyxia. 



679 



recovered after as long a period of apparent death as an hoar. While 
these movements are being carried on the patulousness of the upper 
air-passages is to be maintained, if possible, by the measures described 
below. The disadvantages of Sylvester's method are that the posture 



Fig. 123. 




Sylvester's method of artificial respiration. Third movement: the patient's arms are raised 
and the elbows approximated to contract the chest. 

of the body does not drain the upper respiratory passage of fluid and, 
further, it rapidly exhausts the operator, since the arms of an uncon- 
scious patient are very heavy and difficult to move. 

The Proper Position of the Head. — In some researches made by 



Fig. 124. 




Sylvester's method of artificial respiration. Fourth movement : the patient's elbow and fore- 
arms are pressed forcibly upon the floating ribs to expel the air from the chest. 

Dr. Martin and the writer the following rules regarding the position 
of the head, neck, epiglottis, and tongue were formulated: The 
fingers are passed behind the angles of the lower jaw and the latter 



DISEASES. 



is pressed forward; this elevates the epiglottis and the base of the 
tongue about a quarter of an inch from the postpharyngeal wall. 
Extending the head and pushing it forward, so that the neck makes 



Fig. 125. 




Showing the attitude in which the head should be held to permit the easy passage of air 
through the glottis. This position raises the epiglottis, and lifts the soft palate from the 
tongue. (Martin and Hare's method.) 

an angle of forty-five degrees with the plane of the table, draws the 
base of the tongue and the hyoid bone far forward, this motion being 
at the same time imparted to the epiglottis, so that the latter stands 



Fig. 126. 




Illustrating how upward traction on the tip of the tongue draws the epiglottis away from 
the glottic opening and permits free ingress of air. It also shows how letting the tongue fall 
back in the mouth in anaesthesia would close the air-passages and permit the epiglottis to 
interfere with breathing. (From a research by Dr. Martin and the author.) 

upright and is separated from the posterior wall of the pharynx by an 
interval of about an inch. By tightly closing the jaw the antero- 
posterior space is still further increased (Fig. 125). 



ASTHENOPIA. 681 

A very useful method of treating asphyxia is that of Laborde, by 
rhythmic traction on the tongue. The tongue is grasped with forceps 
and pulled well forward and upward from ten to fourteen times a 
minute until voluntary respirations occur. The sensory nerves of the 
tongue carry impulses to the phrenic centre, which in turn causes the 
diaphragm to contract. A very large number of recoveries from 
apparent death as a result of its use renders this method most worthy 
of trial. 

The absurdity of the application of the rapidly interrupted electric 
current to the phrenic nerve is not alone dependent upon the points 
we have named. (See Ether.) It has been proved by careful obser- 
vation on the part of Dr. Edward Martin and the author that the 
application of the electrode over the phrenic nerve in the neck may 
cause cardiac arrest through diffusion of the current to the vagus nerve, 
and Griswold reached conclusions of an identical character in 1885. 

If electricity is used, it should be employed solely as a peripheral 
irritant, with the object of arousing the patient, as would the dry 
electric brush. 

ASTHENOPIA. 

Asthenopia, or weak sight, depends upon exhaustion of the power 
of accommodation in cases of refractive error, usually hypermetropia, 
or upon imbalance of the external ocular muscles. The former is 
sometimes called accommodative asthenopia, and the latter muscular 
asthenopia. The treatment of these conditions requires the prescrib- 
ing of proper lenses, combined, if necessary, with prisms and with 
systematic exercise of the ocular muscles. Locally, a weak solution 
of the sulphate of eserine or pilocarpine acts as a stimulant to the 
ciliary muscle, and good results follow the internal use of large doses 
of the tincture of nux vomica or strvchnine. 



Or, 



3— Eserine sulpha tis gr. T V (0.016). 

Aquse destillatse fgj (30.0).— M. 

S. — 2 drops (0.1) night and morning. 

]$ — Pilocarpinse nitratis gr. ^ (0.003). 

Aquse destillatse ... ....... fgj "(30.0).— M. 

S. — 2 drops (0.1) night and morning. 



Another form of asthenopia is termed neurasthenic asthenopia, or 
retinal anaesthesia, and presents a number of eye-symptoms in con- 
nection with a general depression or debilitated state of the nervous 
system, the eye itself, however, being a healthy organ. The chief 
symptoms are fluctuation in visual acuteness, rapid disappearance of 
objects looked at, contraction of the field of vision, imperfect retinal 
images, often associated with dread of light. Correction of refractive 
error is an essential procedure, but is not sufficient. The patient 



682 DISEASES. 

requires the same general treatment that would be applied to any 
neurasthenic case. All the functions of the body must be carefully 
examined into and placed in as normal a condition as circumstances 
will allow. Especially valuable are rest, massage, salt baths, and full 
doses of strychnine, together with iron if there be ansemia. 

ASTHMA. 

Asthma is one of the most difficult diseases to treat successfully that 
the physician has to deal. 

The disease in all its forms depends upon interference with the free 
entrance to and exit of the air from the lungs, and this is generally, if 
not always, dependent upon a spasm of the muscular fibres in the 
walls of the bronchial tubes, although it has been asserted to be due to 
a sudden swelling or hyperemia of the bronchial mucous membrane. 
Both of these states are probably present in varying degree in all 
cases. 

The spasm has been proved by Longet, Williams, Romberg, Paul 
Bert, Bierner, and more recently by Sandmann, to be due to a neu- 
rosis of the pneumogastric or vagus nerve, and the swelling of the 
mucous membrane has been seen by Stoerk and others. Thus two 
schools of teaching concerning the pathology of this disease have been 
formed, when a little attention to the physiology of the subject would at 
least show that no difference need exist, for the vagus nerves govern 
not only the muscular fibres, but also the bloodvessels of the bronchial 
tubes. The discovery of Michaelson that injury of the recurrent 
laryngeal nerves causes catarrhal inflammation of the bronchial tubes, 
particularly those of the upper lobes, renders the analogy between 
acute asthma and laryngeal spasm, which has been spoken of by many 
writers, still more interesting. 

One other step remains for a thorough understanding of the man- 
ner in which the disease is produced. Gastric, dyspeptic, or intestinal 
asthma arises from indigestion, as its name implies, and is caused by 
the irritation of the afferent filaments of the vagus in the walls of the 
stomach and intestine, thereby causing reflexly a contraction and 
hyperemia of the bronchial tubes. In a similar reflex manner abnor- 
mal conditions of the nasal mucous membranes in general may result 
in an asthmatic attack. There is also some evidence that small 
collections of pus in the nasal sinuses may reflexly cause asthma, or 
by the absorption of the pus the asthma may be a form of anaphylaxis. 

Having obtained some idea of the cause of an attack, let us turn to 
the treatment of the affection. 

As soon as the patient is seen 5 to 10 minims (0.3-0.65) of adrenalin 
solution (1: 1000) should be given hypodermically ; in other cases the 
same amount of pituitrin may be used. They act by relaxing the 
bronchial muscular fibres. If they fail, which is rarely the case, 
morphine hypodermically in the dose of | to } grain (0.01-0.015), alone 
or in combination with atropine, should be resorted to. 



ASTHMA. 683 

One of the most serviceable remedies in asthma is belladonna, 
which, as has been pointed out when that drug was studied (see Bella- 
donna), exercises in medicinal dose a decided sedative and depressant 
influence on the peripheral filaments of the vagus nerves, not only so 
far as the heart is concerned but also through the pulmonary fibres, 
upon bronchial secretion, which is always diminished by the drug, 
probably by its vagal influence. 

It is evident, therefore, that the use of belladonna or atropine, 
although originally employed in an empirical manner, rests upon a 
rational basis, and as the physiological action of stramonium, hyoscy- 
amus, and similar members of this group is nearly identical with that of 
belladonna, their influence for good is also explained. The experiments 
of Ott prove that lobelia is a peripheral pneumogastric depressant, 
and those of Rosenthal and the author likewise showed that tobacco 
has a similar effect. The same is also true of nitrite of amyl and the 
other nitrites, which also relax un striped muscular fibre. We have 
before us, therefore, a list of the most efficacious and best anti-asth- 
matics, all of them being depressant to the peripheral vagi. 

The other remedies commonly employed are chloroform by inhala- 
tion, which relaxes the spasm of muscular fibre by its local influence, 
and morphine, which acts as a nervous sedative, prevents reflex irri- 
tation, and quiets the patient, acting at the same time as a heart stim- 
ulant and unloading the engorged cardiac cavities. The relief obtained 
by the inhalation of the fumes of nitrate of potassium, See asserts, 
depends upon the formation of the protoxide of nitrogen and carbonic 
acid gas, which act as local anaesthetics. 

Cigarettes made of paper soaked in a solution of nitrate of potassium 
and belladonna may be smoked (see formula under Belladonna), or 
they may be made in the following manner: 

1$ — Belladonnse foliorum gr. vj (0.40). 



Hyoscyami foliorum 
Stramonii foliorum 
Extracti opii . 
Aquae laurocerasi . 



gr. iij (0.2). 
gr. iij (0.2). 
gr. i (0.015). 
q. s. — M. 



These various leaves are broken up like commercial tobacco, and 
moistened by adding the cherry-laurel water, which should contain 
the opium. Finally, a whole leaf soaked in the same fluid is used as 
a cover, or a piece of cigarette paper may be employed in the same 
manner. 

In some cases a very useful treatment is the smoking of nitre-paper 
cigarettes, which are prepared, before rolling, not only by soaking the 
paper in a solution of nitrate of potassium (see Nitrate of Potassium), 
but also by dipping them, after drying them, in tincture of belladonna 
or stramonium, and allowing the alcohol to evaporate from the paper 
while it is hung in the air. 

Another remedy recently brought forward in this country for the 
relief and cure of asthma is euphorbia pilulifera, the fluidextract of 
which may be given in the dose of \ to 1 drachm (2.0-4.0) once, twice, 
or thrice a day. (See Euphorbia Pilulifera.) 



684 DISEASES. 

The author finds the following formula very useful in asthma: 



1$ — Sodii iodidi 

Potassii bromidi 

Fluidextracti euphorbia? piluliferae 

Nitroglycerin! 

Tincturse lobelia? ... 

Fiat tabella vel capsula No. 1. 
S. — From 1 to 4 three times a day. 



gr. ij (0.12). 
gr. ij (0.12). 
mhj (0.2). 
gr. ,>ihf (0.0003). 
TUiv (0.25).— M. 



If desired, this formula may be given in the form of an elixir. 
• It will be seen that each ingredient of this recipe has a different action 
The action of the iodides in asthma is well known, as is also that of the 
bromides. The euphorbia pilulifera has been found useful in asthma 
empirically. The nitroglycerin depresses the peripheral ends of the 
vagus nerves, and acts as a stimulant to the heart when engorged with 
blood by removing the inhibitory action of the vagus and relieving the 
bloodvessels elsewhere. The tincture of lobelia acts as a depressant 
to the vagus also. 

A valuable prescription for asthmatics to take between the attacks, 
particularly in those cases which have cardiac symptoms, is the one 
calling for digitalis, strophanthus, and nitroglycerin, in the article on 
Angina Pectoris. 

Sometimes a cup of strong coffee taken at the beginning of a par- 
oxysm will abort it. 

The use of amyl nitrite by inhalation, 3 to 6 minims (0.20-0.4) on 
a handkerchief, is invaluable in many cases, and it rarely fails to 
relieve the spasm. Owing to the engorgement of the heart conse- 
quent upon the embarrassment of respiration, this nitrite must be used 
with care, and in one or two instances it has proved dangerous by 
causing cardiac failure. 

Sometimes tobacco may be smoked, and it is particularly efficacious 
in those who are not accustomed to its constant use. 

Lobelia when employed should be used in full emetic dose (2 
drachms [8.0] ), in the form of the tincture if an attack is imminent. 
If an attack is feared, 20 minims (1.30) of the tincture every four 
hours may be given if the heart is in good condition. 

A treatment of asthma which is very successful when it arises from 
nasal disorder consists in the application to the nasal cavities, at the 
onset of the attack, of the following solution by means of a brush or 
spray : 

1$ — Cocainse hydrochloridi gr. xv (1.0). 

Aqua? destillatse . . . . q. s. ad f 5iv (16.0). — M. 
S.— Apply as directed. 

If this solution is thoroughly applied and the other directions given 
are carried out very rapid relief will often be obtained. Under no 
circumstance is the patient to be allowed to make these applications, 
for if he does he is almost certain to develop the cocaine habit. 
The physician should make them and not reveal the nature of the 



ASTHMA. 685 

drug used. Unfortunately, we cannot readily separate those cases 
which are due to nasal disease and those produced by other causes, 
and in consequence this treatment when tried for the first time in a 
given case is purely experimental unless we can discover some hyper- 
sesthetic patch in the mucous membrane. 

A considerable number of cases have been recorded in which the 
injection of antidiphtheritic serum has given almost immediate relief 
from an attack of asthma, but, on the other hand, it has been proved 
that asthmatic patients are often hypersensitive to this agent and 
are more prone than ordinary persons to the development of that 
dangerous condition, caused by the injection of the serum in rare 
instances, called anaphylaxis. (See Diphtheria.) Antidiphtheritic 
serum is, therefore, a dangerous remedy in asthma, and particularly 
so if it has been previously used, since the primary dose or doses may 
have sensitized the patient. 

The curative treatment of asthma in many cases to a very large 
extent rests upon the use of iodide of potassium, and in the careful 
regulation of the diet and bowels, particularly if the trouble seems to be 
dependent upon indigestion. As the attacks are generally nocturnal, 
the evening meal should be taken early, be light and easily digested, 
and tea and coffee should be avoided at this time. The patient should 
avoid dusty streets and live in the open air as much as possible, and a 
damp atmosphere is usually preferable to a dry one, provided it is not 
cold. This rule is subject to many variations, and each case will be 
found to be a law unto itself. Each patient must try different climates 
until the proper one is found. Arsenic may be used, particularly if 
the mucous membranes are below par, and a dose of bromide of potas- 
sium or sodium, 30 grains (2.0) half an hour before retiring may be 
of service. Sometimes the use of mixed phylacogens does great good. 

Grindela robusta is largely used as a prophylactic in the dose of 
10 to 30 minims (0.6-2.0) of the fluidextract three times a day. Lobelia 
may also be used in the form of the tincture, 20 minims (1.3) three 
times daily. 

The use of compressed and rarefied air is sometimes of service. 
Inhalations of oxygen are valuable if the cyanosis is extreme. 

In many cases great relief will be given by the use of the bronchitis- 
tent. (See Bronchitis.) 

In those cases in which the presence of nasal polypi or other irrita° 
tions of the air-passages is the exciting cause of the attacks those 
causes must be removed before a cure can be obtained. In other 
instances arsenical wall-papers are the cause of the trouble. In all 
cases of asthma the physician should from time to time examine the 
urine and the heart to determine if the attacks are due to disease of the 
kidneys or to congestion from cardiac failure. 



686 DISEASES. 



BED-SORES. 



Bed-sores depend upon disturbances of nutrition resulting from 
pressure exercised in such a manner that the local circulation is inter- 
fered with at a time when the vitality of all the tissues is depressed 
by disease or injury. In most instances the part involved becomes 
chafed by creases in the sheets, by crumbs of food, or by moisture 
from the discharges of the rectum and bladder. Bed-sores can usually 
be avoided by cleanliness unless they are dependent upon disease of 
the trophic nervous system. 

The chief indication is to prevent the trouble by careful nursing and 
cleanliness, which should be supplemented by measures devoted to the 
hardening and improving of the nutrition of the skin covering the parts 
where the sores are apt to appear, as over the buttocks and sacrum. 
To permit of "a good supply of blood, the patient should be turned on 
one side or the other every few hours and the skin of the part which 
has been pressed upon rubbed thoroughly with a dry towel to cause a 
healthy circulation and interchange of the nutritive juices. Salt and 
whisky, 2 drachms (8.0) to the pint (480.0), may be rubbed over the 
skin, and tincture of gambir or the dilute solution of the subacetate of 
lead applied to harden it. If this is not used, a mixture of alum and 
spirit of camphor is useful, made by adding 1 ounce (30.0) of pow- 
dered alum to the whites of 4 eggs and mixing this with 2 ounces (60.0) 
of the camphorated spirit. Where the skin is very red and angry- 
looking, but still intact, a solution of nitrate of silver of the strength 
of 20 grains to 1 ounce (1.3: 30.0) is to be thoroughly painted over the 
spot. All these remedies act by hardening the skin through their 
astringency, or by acting as sedative astringents to the inflamed but 
relaxed capillaries of the part. 

When a bed-sore is developed, measures must be taken for its cure 
and the prevention of its spread. With this object in view the body 
must not rest on the part affected if this can possibly be avoided, and 
in order that the sore may be protected and the pressure equalized , a 
large piece of soap-plaster, with its edges deeply incised to make them 
pliable, should be applied after the sore has been thoroughly washed 
out by means of a swab or syringe filled with a 1:5000 solution of 
bichloride of mercury, and afterward dusted with iodoform or with 
chloretone and boric acid in equal parts. Sometimes large squares 
of lint thickly covered with zinc ointment are serviceable in lieu of 
the soap-plaster. If the sores spread and burrow through the parts, 
the sinuses should be freely opened and irrigated with peroxide of 
hydrogen, all dead tissues being cut away to avoid sepsis. 

Nitrate of silver in the strength of 20 grains to 1 ounce (1.3 : 30.0) 
may also be used locally as the patient recovers if the ulcers seem 
sluggish. A smooth slip-sheet should always be placed under the 
buttocks. If possible, supportive measures and an increased amount 
of predigested food should be given if the sloughs are large. The 



BILIOUSNESS. 687 

internal use of iron is particularly valuable in the form of the tincture 
of the chloride in full doses (say 20 minims [1.3]) every four hours. 

BILIOUSNESS. 

This is a term used to designate a state which presents different 
symptoms in different cases, but always includes languor, headache, or 
dizziness, perhaps some yellowing of the skin and conjunctiva, and a 
general sense of atony, mental depression, and discomfort. It depends 
not upon an excessive secretion of bile, but upon some perversion of 
the functions of the liver or the retention of bile in the bile-ducts. 
Further than this, most of the symptoms do not depend directly upon 
the changes in the bile, but upon failure of proper digestion in the 
stomach and intestine, coupled with the development of toxic de- 
composition-products of various kinds. The stomach, intestine, 
liver, pancreas, and their juices all form a complex interwoven chain 
of function in which if one link breaks the entire chain becomes dis- 
turbed. The entrance into the stomach of certain food-stuffs which 
are either ill-prepared or improper for gastric digestion rapidly causes 
the development of active fermentation, with the formation of lactic 
and butyric acids, which irritate the gastric mucous membrane, and 
thereby bring about a faulty gastric secretion of mucus, which makes 
still further trouble. 

By the same means the circulation of the stomach is disturbed and 
becomes abnormal, and the intestine, liver, and pancreas receive reflex 
irritation to which they are not normally exposed. Further than this, 
the irritated stomach fails to convert its contents into peptones and the 
general features of chyme, and too early or too late drives out into the 
duodenum a mass of semi-digested and fermenting material entirely 
unfit for intestinal digestion and absorption, thereby disordering the 
functions of these parts still further at a time when they are not prepared 
for the reception of any food. The secretion poured out by the differ- 
ent glands varies from the normal; the alkaline juices are not able to 
overcome the normal acid of the gastric juice plus the lactic and buty- 
ric acids ; and finally the reaction of the intestine becomes acid instead 
of alkaline, with resulting irritation and secretion of morbid juices and 
mucus. The trouble when existing in the stomach gives rise to head- 
ache and discomfort, a bad taste in the mouth, and perhaps pain, and 
is followed by fever, langour, jaundice, and flatulence when the intestine 
is affected. 

The cause of these symptoms rests upon the fact that, while gastric 
juice and bile are antiseptic, pancreatic juice mixed with food undergoes 
rapid decomposition, with the development of products of decomposi- 
tion such as skatol and indol and a large number of poisonous alkaloids. 
Normally, these are not allowed to form, owing to the presence of anti- 
septic bile, which also hurries on the absorption of the fats; but if 



688 DISEASES. 

the bile is retained in the ducts, its excretion is impaired and its consti- 
tution altered by the disorder of the liver which results reflexly from 
the gastric and intestinal irritation. Unfortunately, the complication 
does not cease at this point, for the liver in health has other functions 
to fulfil, one of the most important of which is the arrest and destruc- 
tion of all poisons of an organic character which come to it from the 
stomach and bowel. Not only are decomposition products destroyed 
by it, but all the vegetable alkaloids are rendered innocuous if present 
in ordinary amounts. 1 The disorder of hepatic function therefore 
permits the entrance into the general circulation of these substances, 
which are very various as regards their powers and effects. Thus, 
Brunton has pointed out that one of these compounds closely resembles 
curare, in that it poisons the peripheral ends of the motor nerves, and 
thereby is at least partly responsible for the muscular relaxation and 
languor often seen in patients suffering from so-called "biliousness." 
Other substances act as do digitalis, atropine, muscarine, and picro- 
toxin, and the number of these various compounds is infinite. 2 

It is impossible to give space to a further consideration of these 
poisons, but what has been said shows clearly that "biliousness" only 
expresses a state in which absorption of the bile is not the chief cause 
of the symptoms, but that other poisons are at work. The methods 
of treating biliousness are therefore not to be considered as depending 
upon some regular routine, but upon a study of the case and its symptoms. 

Very frequently, after several days of minor discomfort, the disorder 
culminates in a severe sick headache, after which vomiting comes on 
and relief is soon obtained. The manner in which vomiting does good 
is very evident. It compresses the liver and expels inspissated bile 
by the compression exercised by the abdominal walls and diaphragm 
in the effort of vomiting, and thoroughly excites to normal secretion 
the torpid glands of the stomach and intestine. The vomiting or lavage 
also rids the stomach of the fermenting masses and bacteria contained 
in them, and renders the alimentary canal more pure. This purity 
may be increased by giving draughts of plain hot water or hot water 
containing a few grains of bicarbonate of sodium or salicylate of sodium. 

When it becomes evident that an attack is about to begin — that is, 
when constipation, slight drowsiness, or languor after meals shows 
the tendency present — one of the two drugs should be used, either podo- 
phyllin if the stools be dark, or calomel if they be light-colored: J 
grain (0.01) of the former to an adult is generally enough, or 1 grain 
(0.06) of calomel divided into six powders, one of which is to be taken 
every fifteen minutes, is a good dose, to be followed in four hours by 
a saline. If the attack is sudden in its onset, no time is allowed for 
these hepatic stimulants, and a saline purge should be used in a good- 

1 See studies of Schiff, Lautenbach, and many others, including Ludwig and Sr hmidl- 
Mulheim. 

2 See the researches of Schweringer, Zuelzer and Sonnenscheim, Bence Jones, Dupre, 
Rorch and Fassbender, Brieger, Schmiedeberg, and Harnach. 



BILIOUSNESS. 689 

sized dose at once, not because it causes a flow of bile, but because 
it sweeps the poisonous matters out of the gut before complete 
absorption can occur, and aids in restoring the normal intestinal 
alkalinity. 

The prevention of "biliousness" depends upon the maintenance of 
a normal, easily digested diet, upon the formation and excretion of 
normal bile, and the prevention of fermentation and decomposition 
in the alimentary tract. 

The term "normal diet" is a very elastic one, and varies with each 
case. While certain forms of food are generally considered good or 
bad, easy of digestion or difficult of assimilation, it nevertheless remains 
a fact that many of the simplest foods are capable of acting as poisons 
in susceptible persons. A large number of persons cannot take milk 
or eggs because their digestion of these substances is faulty, and 
the writer is cognizant of one case where lobster salad can be eaten at 
bedtime without discomfort, while an egg at breakfast will cause a 
severe headache or pain in the belly. Coffee is often the cause of 
biliousness. Rules as to diet must not be 'ironclad," but based on 
observation in each individual case. 

By far the best means of maintaining hepatic activity in cases where 
this organ is torpid is horseback exercise, particularly if the exercise 
is taken on a trotting horse, as the jolting of the liver keeps the chain 
of digestive functions active and prevents the secretions from becoming 
clogged. Along with this exercise massage of the hypochondrium 
and belly- walls is useful, and the movements of stooping over, bending 
from side to side, and bending backward with the feet close together, 
are of value. 

The use of pure (undiluted) nitrohydrochloric acid in these cases in 
the dose of 5 minims (0.3) three times a day in half a tumblerful of water 
is invaluable, and the fluidextract of stillingia in the dose of 20 minims 
(1.3) is of service, as is also the solid extract of euonymus in the dose 
of 3 grains (0.20). Five-grain (0.30) doses of extract of chirata in pill 
are also useful in hepatic atony of a mild type. 

3$— Extracti chiratse gr. xl (2.6). 



Podophyllini 

Euonymini 

Leptandrini 

Creosoti. . . 
Fiant pilulae No. xx. 
S. — One pill every night. 



gr. iv (0.25). 
gr. viij (0.5). 
gr. viij (0.5). 
gr. x (0.60).— M. 



The knowledge of the action of many of the poisonous materials 
formed in the alimentary canal renders it possible for us to relieve the 
patient by other means than those which may be generally resorted to 
when the attack is present. Thus if the pulse be slow and full, the 
arterial tension high, and there is throbbing in the head, with frontal 
headache, the toxine representing digitalis may be antidoted by the 
use of aconite. If nervousness and irritation are present, the bromides 
and chloral may be used. 
44 



690 DISEASES. 

The use of caffeine in the headaches of biliousness nearly always 
makes them worse, particularly if the headache is due to overindulgence 
in coffee. (See Headache.) 

If the face is flushed, a mustard plaster or dry cup to the nape of the 
neck may be used, and a hot foot-bath is often of service. 

In cases where the bilious attacks are associated with catarrh of 
the stomach, intestines, or bile-ducts, chloride of ammonium, in 
5-grain (0.3) doses, three times a day, is very useful, as is also the 
protiodide of mercury, when triturated with sugar of milk, in the dose of 
-gV to jq- grain (0.001-0.0015) three times a day. Frequently the use 
of salol or aspirin in 10-grain (0.6) doses, three times a day, does 
much good in these cases, acting as an intestinal antiseptic. (See 
Salol.) 

BLEPHARITIS. 

Blepharitis is divided clinically into an ulcerative and a non-ulcera- 
tive variety. The indication of prime importance in the treatment 
of this affection is the removal of the scabs and crusts before the 
application of the local remedies. This may be accomplished by 
the use of alkaline solutions, bicarbonate or biborate of sodium (8 
grains to the ounce [0.5 :30.0]), or daily gentle scrubbing of the lid 
margins with the lather of a good neutral soap. The salves that have 
met with the greatest success are Pagenstecher's ointment (yellow oxide 
of mercury, 1 grain [0.06], vaseline, 1 drachm [4.0]), dilute citrine 
ointment, aristol ointment, boric acid ointment, or a 3 per cent, milk- 
of-sulphur ointment, to which resorcinol may be added. The latter 
application is useful in the squamous variety alone. Blepharitis due to 
the presence of the Morax-Axenfeld bacillus should be treated by 
application of a 1 per cent, solution of sulphate of zinc. In the ulcerated 
form, if the crusts are tenacious, these, as well as the stunted cilia, must 
be removed with forceps, and yellow-oxide-of-mercury ointment, or 
some similar application, applied. Excellent results follow touching 
the crater-like abscesses in the edges of the lid with nitrate of silver. 
If there is an accompanying conjunctivitis, a boric-acid solution is 
suitable, while in any circumstances obstruction of the lachrymal duct 
— a frequent accompaniment of the disease — must be removed and the 
nasal passages explored for any chronic inflammatory condition. The 
relation between this disease and refractive errors demands the correc- 
tion of the latter before a hope for cure may be entertained. 



BOILS. 

Boils are dependent upon an impoverished state of the system, or, 
more rarely, on some local trouble situated in the skin, as in the persons 
of oil- or paraffin-workers, 



BOILS. 691 

The constitutional treatment rests upon the use of fresh air, cod- 
liver oil, iron, arsenic, phosphate of sodium, and, if any boils are 
present, the use of sulphurated calcium in the dose of y-Q grain (0.006) 
every five hours. The sulphurate of calcium hastens the matura- 
tion of boils and prevents the formation of new ones, but is useless, 
according to its original user, Dr. Ringer, in the boils which appear 
during the course of some cases of diabetes. 

The local treatment of boils may be divided into the abortive and 
curative methods. The abortive method consists in painting the 
inflamed spot, when the trouble first begins, with solution of gun- 
cotton (collodion), and renewing the coat hour after hour until a 
heavy contractile covering is formed. The centre of the swelling must 
not be covered by collodion. If pus forms under this, it may be ab- 
sorbed; but if this does not occur, then the boil must be opened under 
antiseptic precautions and properly dressed. A strong solution of 
nitrate of silver is also very useful at the beginning of the forma- 
tion of a boil if painted over the part in the strength of 20 grains 
(1.3) to the ounce (30.0). The other local applications consist in the 
use of the extract of opium or belladonna over the part to relieve pain 
and decrease the inflammation. Poultices may also be used to relieve 
the sensation of tenseness and mature the boil, and should contain 
sweet oil and laudanum. 

Ringer recommends the application cf alcohol and camphor over the 
skin in the early stages. After the skin is wiped dry it is to be smeared 
with camphorated oil. Stelwagon uses the following: 

]^— Ichthyolis . _ 3j (4.0). 

Emplastri plumbi 3ij (8.0). 

Emplastri resinae (U. S. P. 1890) . . . 3ij (8.0).— M. 
S. — Apply to the part. 

He also approves of the injection of a few minims of a 5 per cent, solu- 
tion of phenol into the apex of the boil if its formation is assured. 

Another useful plan after the boil has formed is to wrap a little ab- 
sorbent cotton around a sharp stick, dip it in phenol and bore it into 
the centre of the boil, taking care not to bore beyond the base of the pus 
cavity. The parts are then washed with peroxide of hydrogen and 
dressed with a 10 per cent, ointment of salicylic acid. If there is a 
large slough that does not come away, the part may be dressed with a 
1 per cent, solution of sodium citrate placed on lint or gauze. 

When boils occur in the external ear, the canal should be frequently 
irrigated with hot water, and if the boil is mature it is to be incised. 
A useful pain-relieving dressing for the boil is as follows : 

1^ — Iodoformi gr. iv (0.25). 

Mentholis gr. ij (0.12). 

Petrolati oj (4.0).— M. 

S. — Smear on cotton plugs and insert in the ear twice or thrice a day. 

The use of staphylococcic vaccine is not to be forgotten. (See 
Vaccine Therapy.) 



692 DISEASES. 

BREAST (INFLAMED). 

Lactation should at once cease and the milk be removed by the aid 
of massage and the breast-pump. A bandage exercising pressure is 
now applied and an ice-bag placed over it. This is only useful in 
those cases in which the glands are the part affected. When the con- 
nective tissue is involved, lead-water and laudanum should be applied 
and saline purgatives used. Belladonna ointment may be smeared 
over the breast with advantage in both forms to check secretion and 
allay inflammation. As soon as pus has formed it should be set free 
by an incision in the line of the ducts. If it be deeply situated, the 
breast should be incised close to the chest and the pockets opened by a 
grooved director or dressing-forceps and packed with gauze. 

In the early stages of the inflammation, if the circulation is bounding, 
it should be thoroughly impressed by aconite or veratrum viride and 
belladonna. 



BRONCHITIS (ACUTE AND CHRONIC). 

In the early stages of bronchitis there is always present a very dis- 
tinct hyperemia, followed by a true inflammation of the mucous 
membrane lining the bronchial tubes. When these changes are con- 
fined to the larger bronchi the term "bronchitis" is employed, but 
when the minute bronchioles are invaded the disease is known as 
"capillary bronchitis." In the article on Pneumonia, and elsewhere 
in this book, the writer has spoken of the various stages of inflam- 
mation, the measures indicated under such circumstances, and has 
described the action of the various drugs. In many cases the phy- 
sician only sees the patient when the second stage of the disease is 
present, but if the individual presents himself promptly, the following 
history and physical signs will indicate the treatment to be employed : 
After exposure, more or less severe, to wet, dampness, or dry cold, a 
sensation of oppression comes on, associated with a feeling of "tight- 
ness across the chest" or a sensation as if a bolus of food was under 
the sternum. Aching and pain may be traced over the lines of the 
bronchial tubes, while the dry, hacking cough increases the discom- 
fort and seems to strain the tubes until each one can be outlined on 
the chest-wall by the patient. The cough, when it occurs, is virtually 
unproductive, and often causes pain in the larynx and throat. On 
making examination by auscultation there will be found over the 
posterior aspect of the chest, between the shoulder-blades, sounds 
of bronchial breathing, which are rougher than normal, and due to 
the air passing over an inflamed, swollen, and roughened mucous 
membrane. This bronchial roughening may be sufficient to cause 
a harsh inspiratory sound over the entire chest, and the expiratory 
sounds may be heard a little louder than usual. No other changes 
from the normal can be noted, but isolated spots of discomfort may 



BRONCHITIS. 693 

be pointed out by the patient, where aches, "catches," or "kinks" 
seem to be present in a previously normal tube. Percussion, palpation, 
and inspection show nothing more of note. Some fever may be present. 
The patient should receive a hot foot-bath, take a glass of hot lemon- 
ade with a little whisky in it, and go to bed at once, in order that, by 
inducing a profuse perspiration, he may relieve the bronchial con- 
gestion. Often a dose of Dover's powder is useful in hearty adults to 
aid in causing perspiration. In children the chest should be well 
rubbed with camphor liniment and a little tincture of aconite be given 
in water with sweet spirit of nitre every hour, as follows : 

ty — Tincturae aconiti n\xxiv (1.50). 

Spirit us aetheris nitrosi foij (8.0). 

Aquae destillatse . . . . q. s. ad foj (30.0).— M. 
S. — A half-teaspoonful (2.0) to a child or a dessertspoonful (8.0) to an adult 
in water every hour. 

In many adults 5 to 10 grains (0.3-0.60) of Dover's powder, with a 
hot drink, are better. 

If the attack is not aborted while the first stage is still present , 
before secretion is established, resort should be had to ipecac and to 
citrate or acetate of potassium, which act as sedatives to the inflamed 
mucous membranes and aid in the formation of secretion, moistening 
the inflamed surfaces and thereby overcoming the dryness and irrita- 
tion. These potassium salts also act as febrifuges, and should be used 
in full doses, as much as 40 grains to 1 drachm (2.6-4.0) a day, 
in addition to the aconite already recommended. The following pre- 
scriptions illustrate their employment : 

1$ — Syrupi ipecacuanhac f3j vel f 3 ii j (4.0-12.0) 

Potassii citratis 5iv (16.0). 

Aquae destillatse . . . . q. s. ad fgvj (180.0).— M. 
S. — Dessertspoonful (8.0) every four hours for a child of five years. 

Or 

ly — Syrupi ipecacuanhae f§j (30.0). 

Succi limonis f§j (30.0). 

Potassii bicarbonatis 3iv (16.0). 

Spiritus aetheris nitrosi foj (30.0). 

Aquae destillatae . . . . q. s. ad f§vj (180.0). — M. 
S. — Dessertspoonful (8.0) every four hours for an adult. This mixture should 
not be corked for some time after it is made. 

For a child this prescription should be reduced just one-half in each 
part, with the exception of the water. 

In some cases, particularly if the patient be a child, large doses of 
the citrate, or other salt, of potassium exert a depressing influence and 
have to be decreased. 

Counterirritation may be applied to the chest in the shape of a 
mustard or spice plaster. If the soreness of the bronchial tubes is not 
relieved by this means, inhalations of steam arising from boiling water 
may be practised, either through a cone, one end of which covers the 



694 



DISEASES. 



top of a pitcher and the other end of which covers the month and nose 
of the patient, or by covering the head and pitcher with a towel. The 
usefulness of this method may be much increased by the addition of 1 
tablespoonful of compound tincture of benzoin to each pint of water. 4 
In young children, particularly in the first stage of bronchitis and in 
the later stages, the use of the so-called "bronchitis-tent" is of great 
value. It consists of a canopy raised over the bed a sufficient distance 



Fig. 127. 




Bronchitis-tent put up by aid of two sheets pinned together and four broomsticks /ashed 
to corners of bed. The steam arises from an Arnold steam sterilizer to which has been attached 
a tube. When in operation the side flap of the tent is dropped. 

to allow of the circulation of plenty of air. Through one side of this 
canopy passes a tube leading from an Arnold steam sterilizer, under 
which is an alcohol lamp to keep the temperature of the water suf- 
ficiently high (Fig. 127). By this means the air breathed by the 
patient is so saturated with moisture that the mucous membrane 
lining the air-passages is soothed and quieted. In order that the full 
benefit of this measure be understood, it must be remembered that a 
mucous membrane in the early stages of inflammation is always dry 
and red, lacking its normal moisture, and that the upper air-passages 
fail to catch upon their surfaces, by reason of their dryness, particles 
of dust, and do not moisten the air before it reaches the lungs. Again, 
it will be remembered that the bronchial mucous membrane is 
covered with ciliated epithelium, which, by the constant, upward, 



BRONCHITIS. 



695 



wavy motion of its cilia, urges out of the lungs all impurities. Dryness 
of the surface at once stops this ciliated movement, with unfavorable 
results. The employment of the "bronchitis-tent" is equally useful 
in adults, but less readily employed, owing to the size of the bed. 

Having considered the treatment of the first stage of bronchitis, we 
pass to that of the second. The condition of the mucous membranes 
is now quite different from that which has just been spoken of. In 
the place of an absolute lack of secretion a profusion of cast-off 
epithelial cells, a large amount of mucus, and more or less liquid 
have been poured out upon the walls of the bronchial tubes, forming 
obstructions everywhere to the ready passage of air. The secretion is 
apt to be more or less viscid and ropy, and, when it is coughed up 
after considerable effort, appears in lumps, particularly in the morn- 

Fig. 128. 




Arnold steam sterilizer, showing self-feeding reservoir and small volume of water to be heated. 



ing. This state is one in which the excitement of inflammation is 
followed by local depression and an effort on the part of the tissues to 
rid themselves of the congestion and of the useless epithelial forma- 
tions. The physical signs on listening to the chest are now found to 
consist in a large number of loose rales, which are distinctly wet and 
moist. Later they become markedly liquid and bubbling, and so cause 
gurgling on inspiration and expiration. Sometimes they are musical 
or squeaking. Generally the latter signs do not come on until the case 
is far advanced, and, if a cure is soon to be reached, they last only a 
few days or hours, as the mucus is so loose as to be easily coughed up 
and the lung readily cleared. 

The object of the physician is to use remedies which will stimulate 
the bronchial' tubes and increase the volume of liquid poured out. 
For this purpose the bronchitis-tent may of course be employed, but 



696 DISEASES. 

the drugs to be used internally are the chloride of ammonium and the 
pitches and turpentines, such as terebene, or even turpentine itself. 

In the majority of instances an ammonium mixture will be the best 
and most serviceable prescription, in one of the following forms: 

1$ — Ammonii chloridi 3ij (8.0). 

Fluidextracti glycyrrhizse f5ij (8.0). 

Aquae destillatse q. s, ad fgiij (90.0). — M. 

S. — Teaspoonful (4.0) to dessertspoonful (8.0) every four hours. 

Or, 

1$ — Ammonii chloridi ........ 5 ij (8.0). 

Misturse glycyrrhizse composite . „ loiij (90.0). — M. 
S. — The same dose. 

The advantage of the latter prescription is the presence of antimony 
in the compound licorice mixture, which tends to increase secretion, 
but is contraindicated if debility exists. 

If the cough is troublesome, a little morphine or belladonna may be 
added, or the following be used particularly if any signs of cardiac 
failure appear: 

1$ — Ammonii chloridi oj (4.0). 

Ammonii carbonatis 3j (4.0). 

Ammonii bromidi 3j (4.0). 

Fluidextracti glycvrrhizse .... f 5iv (16.0). 

Aquae destillatse "....... f §vj (180.0.).— M. 

S. — Dessertspoonful (8.0) every four hours. 

In this prescription the first constituent acts particularly on the air- 
passages, the second stimulates the heart and respiration, and the 
third allays the cough, while the liquorice masks the salty taste of the 
ammonium. Still another recipe is: 

ty — Codeines sulphatis gr. ij vel iv (0.12-0.25) 

Ammonii chloridi 3j (4.0). 

Fluidextracti glvcyrrhizae . . . . f oj (30.0). 
Aquae destillatse . . . . q. s. ad fgij (60.0).— M. 
S. — Teaspoonful (4.0) every two hours in water. 

An oronasal respirator, with the sponge saturated with equal parts 
of terebene, iodide of ethyl, and chloroform, may be worn in order to 
allay cough and loosen the mucus. Sometimes the use of a nebulizer, 
as shown on page 605, is very useful, or Yeo's inhaler may be used. 
(See Creosote, Part II., and Inhalations, Part III.) 

If the administration of the chloride of ammonium does not aid in 
the expulsion and liquefaction of the secretion and rid the lungs rapidly 
of the mucus, the use of terebene in 5- or 10-minim (0.30-0.60) cap- 
sules may be resorted to with success. If capsules cannot be sup- 
plied, terebene may be made into an emulsion with acacia or trag- 
acanth and given in this way. Sometimes terebene will irritate the 
kidneys and produce a sense of weight across the loins; if this occurs, 
its use should be stopped. In other cases it will disorder the stomach, 
or cause diarrhoea. These effects are not, however, commonly seen. 



BRONCHITIS. 697 

Terpine hydrate in 10-grain (0.6) doses may be used three times a 
day, or terpinol in the dose of 8 to 10 grains (0.5-0.6) in capsules or 
pills. 

An excellent combination is the elixir of terpine hydrate with 
heroin, which may be given in the dose of a dessertspoonful (8.0) every 
four hours in a little water. Certain of the volatile oils and resins are 
also of value at this time, notably the oleoresin of cubebs and copaiba, 
which, however, possess the disadvantage of disordering the stomach. 
The oil of eucalyptus is also of great value, and may be given in capsule 
or emulsion in the dose of from 1 to 5 minims (0.06-0.30) every five 
hours. The oil of sandal-wood in the dose of 5 to 10 minims (0.30-0.60) 
is very valuable, and is not so apt to disorder the stomach, bowels, and 
kidneys as are some of the other remedies named. 

While the proper use of these remedies usually brings about the 
results desired, in some cases a stage of profuse secretion comes on 
which in its treatment is identical with that seen in chronic bronchitis, 
and chronic " winter cough" with emphysema, so these diseases will 
therefore be considered together. 

In old persons suffering from dilated bronchial tubes, from emphy- 
sema, and from chronic bronchitis there is constantly poured into the 
air-passages so free a secretion that persistent coughing is necessary 
to rid the lung of enough of the mucus and liquid to enable them to 
breathe. Any excess of this exudation drowns him in his own secre- 
tions, and the constant obstruction to the ready flow of air and blood 
in the lung soon produces dilatation and weakness of the right side of 
the heart. 

The same condition in a more acute form sometimes asserts itself 
in young children and in adults. In children it sometimes comes 
on so suddenly as to be known as " acute suffocative catarrh," while 
in older persons it appears with sufficient severity to make the con- 
dition of the patient most serious. Of the treatment of the latter 
state the writer will speak at once. 

The objects desired are to rid the lung of the liquid secretions, to pre- 
vent the outpouring of more exudate, and to support the patient until the 
crisis is past. Digitalis should be administered to support the heart, and 
strychnine be employed in full dose to stimulate the respiratory centre 
and excite the nervous system, which is generally depressed by the 
increasing carbonic acid in the blood. For the same purposes caffeine 
or strong coffee may be used. Oxygen may be inhaled, and to check the 
profuse secretion atropine should be used by the mouth or hypoder- 
mically. When cyanosis is marked and the patient is a child, it 
may be alternately dipped in a tub of hot and cold water to cause 
reaction and stimulate the dormant nerve centres to greater activity, 
and so by reviving the patient sufficiently, respiration is maintained 
until voluntary efforts are made by the patient. Sometimes letting 
the patient hang his head over the side of the bed when he coughs 
may aid in the expulsion of the liquid. 



698 DISEASES. 

^ The treatment of the more moderate condition of excessive secre- 
tion in the bronchitis of old persons, which is more slow in its progress, 
but which may end as fatally as like attacks in the young, is some- 
what similar to that just given. Injurious results are'often produced 
by the physician failing to recognize that the secretion is sufficiently 
fluid, and that ammonium chloride and such expectorants are not only 
useless, but distinctly harmful because they increase the quantity of these 
liquids. Under these circumstances the application of several dry cups 
over the bases of the lungs posteriorly often gives a great deal of relief: 
or if cups cannot be obtained, then active counterirritation by means of 
a mustard-plaster or turpentine stupe is advisable. The cups are, 
however, the remedy of choice. Atropine, which checks secretion, 
stimulates the respiratory centre, and is for this reason a doubly useful 
remedy. Strychnine is, however, the best of remedies to help the 
patient get rid of the sputum. It should be given in the dose of -£$ 
grain (0.006), or more, three times a day. When the condition is 
pressing atropine and strychnine should be used hypodermically. 

The use of remedies designed to allay the cough in these cases is 
absolutely unjustifiable, as it results in retention of the profuse secre- 
tion. The question as to whether the cough is excessive or not must 
depend on the ability of the lungs to rid themselves of the secretions 
in the bronchial tubes. 



BURNS AND SCALDS. 

The treatment of burns and scalds is both internal and external, 
the first being devoted to the relief of pain, and the treatment of 
shock ; and the second to the care of the injured surfaces. Immediately 
upon being called to a severe case of burn it is the duty of the physi- 
cian to determine how badly shocked the patient is, what the condi- 
tion of the pulse may be, and whether or not the lungs and air-passages 
are involved. After these mental notes he should give a hypodermic 
injection of \ to J grain (0.015-0.03) of morphine and y^ of atropine 
(0.0006), and then roll the entire body in a large blanket to maintain 
the bodily heat, while the sufferer is being transferred to the hospital 
or the house to which he belongs. 

In some cases the shock is so great that the pulse flags at once, the 
temperature falls, and collapse ensues. Stimulants hypodermically, 
external heat, and drinks of hot water and whisky are indicated, fol- 
lowed by j-q grain (0.003) of strychnine and \ grain (0.03) of digitalone 
if the circulation does not respond to the less powerful stimulants. 
Adrenalin chloride, 1 drachm (4.0) of a 1 : 1000 solution may be given 
intravenously in a pint of normal saline solution in severe cases, or 
normal saline by hypodermoclysis to the amount of \ to 1 pint (250- 
500). A very useful treatment under these circumstances is to 
immerse the patient in a bath of normal saline warm enough to main- 



BURNS AND SCALDS. 699 

tain the bodily temperature. Often while in this bath the burned 
cuticle is easily removed with but little pain, and the protection from 
the air decreases dermal irritation. The patient should be allowed to 
remain in the bath as long as shock lasts. The treatment of this state 
is far more important than the care of the burns. The removal of 
clothing and the application of dressings must wait until the patient 
has rallied well. (See article on Shock.) 

In the local treatment of burns, the best treatment in some cases 
is the application of a solution of picric acid on lint or wet picric acid 
gauze. Oily dressings are dirty surgery. The picric acid solution is 
of the strength of 1 per cent, in water, and after the lint or gauze is 
applied the parts are covered with a dressing of absorbent cotton and 
a bandage. The gauze used should be in comparatively small sections 
since it is easier to remove in this form than in one large piece. If 
blisters or blebs are found, these should be punctured but not removed. 
This dressing in moderate burns is allowed to remain in place until 
healing is complete. In severe burns or scalds it is changed on the 
second or third day, the first dressing being softened before removal 
by applying some of the picric acid solution. This treatment relieves 
pain, prevents suppuration, and results in a smooth cicatrix. If 
suppuration occurs, the parts are to be washed free of picric acid by 
means of normal salt solution, followed by hydrogen peroxide solution, 
then, after drying with compresses of cotton, dressed again with 
picric acid. Fingers and toes are to be separated by wet pieces of the 
gauze or lint. Indolent healing is best treated by resin cerate. 

Still another very efficacious application to burns is that of the 
late Professor Rice. It is better than Carron oil or any of the prepa- 
rations ordinarily used. It is as follows : 

1^— White gelatin oviiss (225.0). 

Glvcerin f§j (30.0). 

Phenol f5i (4.0). 

Water fgxvj (480.0). 

Soak the gelatin in the water until it is soft; then heat it on a water-bath 
until it is melted. Add the glycerin and continue heating until a firm, glossy 
skin begins to form on the surface of the mixture, in the intervals of stirring. 
Now add the phenol and mix intimately. 

This mixture may be kept ready prepared, and is best preserved in 
well-closed glass or porcelain jars. When wanted for use, it is heated 
on a water-bath until just melted, and applied with a soft flat brush 
over the burned part, where it forms a strong flexible skin. 

During the great war the following formula has been largely used 
as a spray from a coarse oil atomizer, the mixture being kept in 
a fluid state by heating above 122° F. In a slightly different form 
it has been called "ambrine." 

Per cent. 

Betanaphthol 0.25 

Oil of Eucalyptus 2.0 

Olive oiL 5.0 

Hard paraffin 25 . 

Soft paraffin 67.75 



700 DISEASES. 

If a spray cannot be had it may be applied with a sterile brush. 

It has become increasingly apparent, however, that such mixtures 
are no better than plain paraffin, and that it is essential after removing 
dirt, opening blebs and clipping off free skin to dry the surface by an 
electric dryer such as is used by barbers or by fanning it, and then 
paint it with liquid paraffin over which is laid a thin layer of cotton 
and over this in turn is painted the melted paraffin. The solid paraffin 
should melt at 50° C. (122° F.) and should be pliable at 28° C. (82.4° 
F.), and several layers of dressing extending over the adjacent healthy 
skin should be applied. This plan gives no better results as to scars 
but is clean, efficient and cheap. The dressing should be changed in 
twenty-four hours, and the wound cleaned not by the aid of liquids 
but by patting it with dry gauze. 

Whenever the urine is high colored and cloudy the citrate of potas- 
sium should be freely given, 20 grains (1.3) in water three times a day, 
combined with 30 minims (2.0) of sweet spirit of nitre. 

CHANCROID. 

The chancroid is a contagious ulcer which has no definite period of 
incubation, is distinctly inflammatory in type, and is usually multiple. 
It is further distinguished from the primary sore of syphilis by the 
fact that it is auto-inoculable, is not followed by secondary eruptions, 
and, if it involves the lymphatics at all, produces an acute inflam- 
matory swelling which frequently attains a considerable size and sup- 
purates. A specific bacillus can be recovered from its discharge. 

Chancroid, being purely a local affection, would seem to require 
nothing more than local treatment; this is true of the uncomplicated 
sore, but where phagedena or serpiginous ulceration sets in, the ques- 
tion of constitutional treatment is of importance. 

The treatment of uncomplicated chancroid in its early stage is as 
simple as it is efficient. One thorough cauterization converts the sore 
into a healthy ulcer, the cicatrization of which is quickly and surely 
accomplished. 

As the most efficient means of thoroughly destroying chancroidal 
ulcerations the actual cautery is chiefly commended. This is, however, 
objectionable to patients. Nitric acid will be found equally service- 
able; it may be applied by means of a glass rod or a cotton applicator. 
The pain of these applications may be greatly lessened by the previous 
employment of a 20 per cent, solution of cocaine. When the surface 
involved is large, the patient should be etherized. The cardinal point 
in the cauterization of chancroids is to reach and destroy all the diseased 
area. Each pocket and sinus must be thoroughly acted upon, other- 
wise it remains as a focus for reinfection. For one or two days after 
cauterization the parts should be dressed with gauze kept wet with a 
mixture of dilute lead-water and alcohol equal parts. Thereafter a 
dry dusting-powder may be used. 



CHANCROID. 701 

There has been a tendency of late years to substitute for this treat- 
ment one less radical, more acceptable to the patient, and in many 
cases almost equally satisfactory in results. Many of the chancroids 
as found in persons of robust health show little tendency to spread, 
and are amenable to mild treatment. It must be remembered, how- 
ever, that as long as the smallest portion of such an ulcer remains 
unhealed, it may at any time take on all the features of a virulent ulcer- 
ation. Moreover, the patient is constantly exposed to the risks of a 
chancroidal bubo — a complication so troublesome that the possibility 
of its development constitutes the strongest argument against palliative 
in distinction from radical treatment. 

Where the ulceration is entirely superficial, constituting the erosive 
form of chancroid, iodoform, dusted over the surface of the carefully 
cleansed granulations, offers the best form of palliative treatment. 
The dusting-powder should be preceded by careful spraying with per- 
oxide of hydrogen 1 : 4, followed by a spray of mercury bichloride 
1 : 4000. The objection to iodoform lies in its odor. To overcome 
this, the powder should be dusted only upon the sore. The odor can 
be disguised to some extent by thoroughly mixing with the iodoform a 
small quantity of one of the essential oils, such as oil of peppermint or 
attar of roses, using not more than 5 minims (0.30) to 1 drachm (4.0) 
of the powder. There is no dusting-powder which can entirely take 
the place of iodoform, yet, when the objections to the use of the latter 
are insuperable, thymol iodide or iodol may be substituted, or a mix- 
ture of 1 drachm (4.0) of zinc oxide and 3 drachms (12.0) of subnitrate 
of bismuth, or equal parts of calomel and bismuth. If the dusting- 
powder be allowed to form a crust beneath which the discharge col- 
lects under some tension, the development of bubo will be distinctly 
favored. It is, therefore, needful when dusting-powders are used that 
the dressing should be repeated several times a day, the lesion being 
first cleansed, then dried by means of absorbent cotton, and finally 
dusted with the powder of choice. Gauze dressing is then secured in 
place by bandages, straps, or, when this is applicable, by pulling the 
foreskin forward. 

Wet applications frequently changed, because of the greater clean- 
liness and better drainage which they insure, are less likely to be fol- 
lowed by complications than are dusting-powders. In the small not 
markedly inflammatory or rapidly progressing lesions it suffices to sup- 
ply the patient with a bottle of antiseptic solution — dilute lead-water 
answers well — and an adequate quantity of cotton or gauze. At each 
act of urination he changes his dressing, retaining it in place in the 
simplest practicable way, spraying the lesion night and morning with 
dilute peroxide solution. When, however, the sore is attacked by a 
high grade of inflammation, prolonged immersion of the part involved 
or of the whole body in hot water is indicated, followed by the applica- 
tion of dressings kept constantly wet with dilute lead-water and alcohol. 

Where the chancroid assumes the phagedenic type, extending with 



702 DISEASES. 

great rapidity and causing extensive sloughing and destruction of tissue, 
free cauterization, either with the hot iron or by means of nitric acid, 
should be instituted immediately, every portion of the ulcerating sur- 
face being thoroughly destroyed. This should be followed by pro- 
longed hot sitz-baths or general warm baths, the patient remaining in 
the water for days at a time if necessary, and, if practicable, eating 
and sleeping with the body still immersed. If this is not possible, 
baths of from two to four hours' duration should be given two or 
three times daily. In addition, the patient may be given full doses of 
opium, and should receive a tonic and supporting treatment. 

Should the chancroid assume the serpiginous type, slowly extending 
in spite of treatment, until in the course of months or years large areas 
are destroyed by the process, the warm bath, continued night and day 
for weeks at a time, together with thorough cauterization of the entire 
diseased surface with the hot iron, represents the most satisfactory 
method of treatment. In phagedenic and serpiginous cases the reac- 
tions for syphilis (Wassermann, Noguchi) should be taken, and if they 
be positive, salvarsan should be given. 

The chancroidal bubo is best avoided by prompt and thorough cau- 
terization of the sore, or by frequent thorough cleansing and the avoid- 
ance of retained discharge; when it occurs, however, it should be first 
treated by rest, pressure, and counterirritation, since it may be a simple 
inflammatory adenitis, and with care may not go on to suppuration. 
The patient should be put to bed, and a compress should be applied, 
kept wet with dilute lead-water and alcohol, and held in place by a 
spica bandage of the groin ; or this may be substituted by compresses 
soaked in ichthyol solution (1 :40), over which is laid a hot-water bag. 
At the first sign of suppuration the bubo should be punctured by a 
tenotome, evacuated, washed out with a bichloride solution (1 : 1000), 
and dressed antiseptically. If there be a reaecumulation of pus, the 
puncture and washing should be repeated. If inflammatory symp- 
toms still persist, the diseased gland should be thoroughly removed 
by dissection or the curette through a free opening, the resulting 
wound being drained by gauze and sutured.. If the bubo take on 
phagedenic action, it should be treated as the phagedenic chancroid. 

CHOLERA, ASIATIC. 

The treatment of this exceedingly dangerous disease is prophylactic, 
curative, and convalescent. 

The first measures consist of strict quarantine, both public and 
private, the avoidance of all water for culinary purposes which has not 
been boiled at least an hour and cooled in a place devoid of germs, 
the use of no uncooked food which may be contaminated, and the 
employment of those foods which, while preserving the normal bodily 
health, in no way predispose to intestinal disturbances, as do some of 



CHOLERA, ASIATIC. 703 

the fruits, as melons and grapes. If these precautions are observed, 
little remains to be done. 

The use of a remedy originally proposed by Dr. R. G. Curtin has 
been proved by recent study to be eminently rational. This agent 
is sulphuric acid. This drug not only is acid, and so deleterious to 
the bacillus, but, in addition, is astringent, and is probably elimi- 
nated as a sulphate by the lower bowel. As is well known, ordinary 
cholera morbus yields readily to its influence. 

Dividing the disease into three stages, we find as the earliest symp- 
tom some disturbance of peristaltic movement, with or without pain, 
or in other instances the patient is attacked with a sudden flux of the 
intestinal contents. If there is a history of the ingestion of bad or 
indigestible food, there is no doubt whatever that this foreign material 
must be gotten rid of by the use of castor oil. No purgative should 
be given unless the history of the ingestion of bad food is most direct 
and clear. 

'When the attack is sudden in its onset, as is usual, the question 
arises, Shall we resort to opium by the mouth? The answer, after 
having carefully considered the statements of a large number of 
authors, is that opium should not be used by the mouth or hypoder- 
mically except, in cases where the pain or cramps are so severe as abso- 
lutely to require the drug. In other words, it is to be given for the 
pain, not for the diarrhea. Should opium be used, it is infinitely 
better to employ it by the rectum in the manner to be described later; 
and if it is necessary to use it by the mouth, only denarcotized opium 
or tincture of deodorized opium should be employed, since these 
preparations are less apt to cause nausea than their fellows. 

Camphor, on the other hand, seems to be universally regarded as a 
most useful drug, tending at once to check diarrhoea and relieve the 
pain and cramps from the beginning to the end of the attack. "Whether 
camphor exercises any germicidal effect on the cholera bacillus we do 
not know. Certain it is that volatile oils all possess distinct antiseptic 
powers. Aside from any such influence, camphor is useful as a gen- 
eral systemic stimulant, and has been proved by wide clinical observa- 
tion to have a very extraordinary power in the control of all forms of 
serous diarrhoea, particularly that of true cholera. The spirit of camphor 
has proved most effective in cholera epidemics. Frequently the use 
of camphor so controlled th^ diarrhoea and stimulated the torpid kid- 
neys that anuria was relieved in twenty-four hours. Under these 
conditions camphor wine has been found very useful; it is made 
by adding 75 grains of finely powdered camphor to a quart bottle 
of strong red wine, to which are also added gum arabic and alcohol. 
The camphor is first dissolved in the alcohol, and then thoroughly 
mixed with the wine. The dose of this mixture is a teaspoonful, 
in peppermint-tea, every hour to a child of six years, for an older 
child a dessertspoonful, and for an adult a wineglassful. Those who 
first used this mixture were wiser than they thought, for the recent 



704 DISEASES. 

studies of Pick have shown that both red and white wine are dis- 
tinctly inhibitory to the growth of the micro-organism of cholera, 
probably because of the tannic or other acid which they contain, as 
well as the alcohol. 

The experience of English physicians in India indicates that per- 
manganate of potassium, given in keratin-coated pills so that it will 
not be decomposed in the stomach, in the dose of as much as 1 drachm 
(4.0) in six hours, is probably even more useful than camphor. 

A remedy, the use of which is based on very rational grounds, is 
salol, and probably the newer drug, aspirin, which, theoretically, is 
much better than the former, because it is less poisonous. According 
to the interesting studies of Lowenthal, salol seems to be peculiarly 
antagonistic to the bacillus of cholera. This investigator added to a 
50-Gm. alkaline solution of pancreatic juice 10 Gm. of salol, and to 
this mixture 3 mils, of a virulent bcuillon culture of the bacillus. Ex- 
aminations in forty-eight hours to a week showed this to be absolutely 
sterile. It was further proved that the salol was inactive until broken 
up into its component parts — phenol and salicylic acid. Hueppe also 
asserts that the use of salol prevents the development of anuria. 

In addition to the treatment already given, which may be used in 
the second as well as in the first stages, we have measures which must 
be resorted to for the relief of the dominant symptoms which mani- 
fest themselves as the disease progresses. 

The symptoms now to be combated are vomiting, purging, toxaemia, 
cramps in the extremities, and, as the result of these, exhaustion, 
collapse, and the advent of the algid stage. By far the best results 
obtained by any one line of treatment at this time certainly follows 
the employment of salol and camphor by the mouth, with intravenous 
injection of saline solution; or, if this is not possible, hypodermoclysis 
and the employment of a hot-water bed; or, hot bottles and bricks, 
for the patient largely dies of cold and of internal congestion. It 
has been found that the strength of the saline solution given by the 
vein should be greater than usual, namely, about 1 per cent., and from 
three to five pints should be used whenever the blood-pressure in a 
European is as low as 80 mm. of Hg., or the specific gravity of his 
blood is more than 1063; 1056 being about normal. The flow should 
be at the rate of about 1 ounce (30.0) a minute. After the intravenous 
injection has rallied the patient the blood-pressure may be maintained 
by giving a rectal injection of normal saline every few hours, or hypo- 
dermoclysis may be resorted to. (See Hypodermoclysis, Part III.) 

Atropine and strychnine are useful, and ether may be given subcu- 
taneously or by the mouth as a diffusible stimulant. If uraemia 
threatens the use of saline by hypodermoclysis, combined with stro- 
phanthus or digitalis by the mouth, or caffeine, pituitrin, or adrenalin, 
may be resorted to to overcome renal stasis. (See article on Diarrhoea.) 



CHOLERA INFANTUM. 705 

CHOLERA INFANTUM. 

It is important to bear in mind that every case of cholera infantum 
is due to the excessive growth of micro-organisms in the alimentary 
canal, and that in a large proportion of cases these organisms find 
entrance to the body through impure milk or water. Disturbed 
digestion due to extraneous causes or to excess of one of the elements of 
the food may be responsible. If the fats are in excess the stools are 
acid in reaction, may contain lumps of fatty soaps looking like curds 
and have a butyric acid odor. Fat curds are small or moderate in 
size, easily broken up and soluble in ether. Placed in water they 
float. When casein is in excess the odor is offensive and the stools 
often alkaline. Casein curds are large and tough, become hard in 
ether and tend to sink in water. When carbohydrates are the cause 
the stools are acid and smell like sour bread. If the nates become 
excoriated the stools are usually acid. In a certain proportion of 
cases micro-organisms find the intestine a favorable place for growth 
solely because the character of the food is bad as to purity, and of 
such consistency or in such proportion that the digestive organs 
fail to deal with it properly. As a result conditions favorable to germ 
growth develop. To prevent this disorder careful feeding is essential, 
and after the child begins to convalesce careful feeding is still im- 
portant. (See Feeding the Sick.) The organisms are those of fermen- 
tation in some cases, or are of the type capable of causing dysentery in 
others. The latter may belong to the type called the dysentery bacil- 
lus of Shiga or that of Flexner. Both of these produce greater toxsemia 
and depression than the fermentative organisms. The gas bacillus 
is not uncommon and is dangerous. It produces an acid stool. 

Every case of this disease is to be considered as an infectious illness, 
and every endeavor made to prevent the growth of malignant organ- 
isms in the bowel, to aid in the elimination of their toxins and as far as 
possible to support the vital forces of the patient. Hot weather pre- 
disposes a child to cholera infantum because it lowers its vitality and 
also tends to increase the growth of micro-organisms in the milk. 

Diarrhoea occurring in an infant in hot weather is to be regarded by 
the physician as a fireman regards a fire. The only way to prevent 
a calamity is to regard it seriously and use every effort to prevent its 
further development. 

Absolute avoidance of milk and the use of a few drops of beef-juice 
in water every hour or two for twenty-four hours are the first orders 
as to diet. If vomiting is active and collapse is threatened, a drop or 
two of good brandy should be used in each teaspoonful of food, 
and the value of atropine as a vasomotor stimulant is not to be 
forgotten. 

If masses of undigested food are passed, a dose of castor oil (1 to 
4 teaspoonfuls [4.0-8.0] to a child of two years), with 20 minims (1.3) 
of paregoric, should be used to sweep out the offending materials and 
45 



706 DISEASES. 

allay irritation, and be followed at once by the treatment which will be 
spoken of later. (See Sodium Citrate.) 

When the diarrhoea is severe there may be much bearing down, or 
in other cases a simple running off of the liquid from the bowel almost 
without effort. Very soon, indeed, the passages become entirely color- 
less, except for a speck or two of green. The diapers have a peculiar 
mousy odor, and are characteristic, that is, they seem to be only wet 
and musty, and contain no solid matter. If closely examined, they 
will be seen to be soiled by a small amount of a whitish substance, 
looking like a paste made of water and fine chalk. Such a passage 
bodes ill for the child unless treatment is instituted. The physician 
should order, at once, A grain (0.003) of podophyllin for a child of six 
months, to be taken in two doses, half an hour apart, in 20 drops of 
brandy with a little water. Two hours after this the dose should be 
repeated, and again in two hours more if necessary. By the end of the 
fourth hour there will be generally seen in the movements of the bowels 
a trace of color, and this will gradually become more marked if the case 
is to have a favorable termination. Calomel may be used instead of 
podophyllin. 

As soon as the movements have changed from the pasty white 
motions named to those having a bilious color, then, and not until 
then, are astringents to be employed. If they are used before 
this, the diarrhoea may become less for a few hours, but the child 
absorbs poisons from its alimentary canal and rapidly goes into col- 
lapse. 

The rationale of this treatment rests upon the fact that owing to the 
disease every gland connected with the alimentary canal has become 
inactive. It is absolutely necessary to bring about glandular activity 
and podophyllin, in the experience of the author, is the best remedy 
for this purpose. During the period that the podophyllin is acting it 
is well to apply a spice plaster to the belly or to immerse the child for 
short intervals in a hot bath, if its extremities are cold, to maintain its 
bodily temperature. 

In practically every case of cholera infantum it is of the utmost 
importance to stop milk-feeding absolutely for a few days. Nothing 
in the way of food may be given, except Valentine's Beef-Juice, 10 
minims (0.60) every two hours with a little cold water, or beef-juice 
expressed from rare rump steak, until curds and undigested food are 
no longer found in the stools. 

Buttermilk, more or less diluted with water and sometimes sweetened 
with a little sugar, is also useful when milk feeding is begun again. 
(See also Sodium Citrate and Casein Milk.) 

When the child is feeble and poorly nourished the stopping of milk 
feeding, as detailed above, may be inadvisable. It is under these condi- 
tions that Bulgarian lactic acid bacillus does the greatest good, since it 
stops putrefaction and permits milk feeding to be continued. As many 
as 10 to 40 tablets may be given in the first twenty-four or forty-eight 
hours if it is to produce a positive effect, but such doses are rarely 



CHOLERA INFANTUM. 707 

necessary. No so-called intestinal antiseptics should be given for 
obvious reasons while the lactic acid bacillus is used. 

The buttermilk with its lactic acid bacilli, or lactic acid bacilli 
given in tablets dissolved in water, inhibit the growth of putrefactive 
organisms, but are contraindicated if the stools are acid in reaction. 

After these measures have been resorted to, and the chief object — 
namely, a bilious stool — obtained, the diarrhoea may be stopped grad- 
ually. The medicinal treatment should consist in the use of a mixture 
such as the following for a ehild of a year or eighteen months: 

Ifc — Acidi sulphurici aromatici gtt. xxx (2.0). 

Tincturae opii camphoratae f 3iij (12.0). 

Elixiris curacoae f 3ij (8 0). 

Aquae cinnamomi q. s. ad f giij (90.0). — M. 

S. — Teaspoonful (4.0) in a little water every two hours. 

Or, 

fy — Acidi sulphurici aromatici gtt. xxx (2.0). 

Tincturae opii camphoratae f 3 J (4.0). 

Fluidextracti haematoxylin fgss (15.0) 

Syrupi zingiberis ...._.. q. s. ad f 5hj (90.0). — M. 
S. — Teaspoonful (4.0) every two hours in water. 

The salicylate of bismuth or sub nitrate of bismuth or phenolsulpho- 
nate of zinc may be tried. (See Cholera Morbus.) 

Where the vomiting is very severe and incessant, the purging pro- 
nise but free from undigested curds, a rectal injection of starch-water, 
2 ounces (60.0), containing 10 drops (0.60) of deodorized laudanum, is 
to be employed, and at the same time J grain (0.01) of gray powder 
(hydrargyrum cum creta) given every hour if the podophyllin is not 
well retained. The gray powder may in turn be substituted by r V 
grain (0.005) doses of calomel. Very minute doses of arsenic given 
by means of the following solution are often of service in checking the 
vomiting and purging, and may be resorted to if necessary : 

1$ — Liquoris potassii arsenitis gtt. j vel ij (0.06-0.12). 

Aquae cinnamomi f oj (30.0). — M. 

S. — Teaspoonful (4.0) every fifteen minutes until four teaspoonfuls (16.0) are 
taken. 

In some cases the remedies named above only check the diarrhoea for 
the time being, and it returns as soon as they are withdrawn.' In such 
a case the following is of value to restore the lost tone of the parts 
involved : 

1^— Resinae podophylli gr. J (0.03). 

Liquoris potassii arsenitis .... gtt. iij vel vj (0.20-0.40) 

Liquoris calcis f 5 iij (90.0). — M. 

S. — Teaspoonful (4.0) every five hours. Shake well before using. 

Or a powder may be used : 

3— Resinse podophylli gr. J (0.015). 

Pulveris ipecacuanha? gr. j (0.06). 

Sacchari lactis gr. xx (1.3). — M. 

Fiant chartulae No. x. 

S. — One powder even' five hours. 



708 DISEASES. 

A very important, never-to-be-forgotten measure in cholera infantum 
is the use of counterirritation over the belly by means of a mustard 
plaster (1 part of mustard flour to 4 of wheat flour) or by a spice plaster. 
This plaster should be renewed as often as it cools, and kept on con- 
tinuously if the skin will stand it. (See Counterirritation.) 

A remedial measure carried out with great success in the treat- 
ment of cholera infantum is the use of irrigation of the bowels, or 
rather washing out of the colon. This is accomplished by the use of 
a pint of cool water containing 1 per cent, of nitrate of silver or of 
the solution named in the article on Enteroclysis. The inflow tube 
should be of soft rubber, like a female catheter. The pressure used 
should be that of a fountain-syringe raised not more than 18 inches 
above the buttocks, and the outflow should be unobstructed. The 
irrigation may be resorted to every few hours, and continued each time 
until clear fluid flows away. The solution should, of course, not be 
too cold nor too hot — say 90° F. if there is fever. (See article on 
Diarrhoea.) 

Hypodermoclysis may be resorted to for collapse or the Murphy 
drip with normal salt solution employed. 

When the patient seems stuporous and has panting respirations an 
examination of the urine may reveal acetone, produced as in diabetes 
by the utilization of fats of the body to compensate for starvation. 
Under these conditions levulose or glucose may be given by the bowel 
or intravenously (see Intravenous Injections and Diabetes), or a 4 
per cent, solution of sodium bicarbonate given intravenously in the 
dose of 75 to 150 mils, every five hours. It cannot be given subcu- 
taneously because if the solution is boiled to make it sterile carbonate 
of sodium is found which will produce a slough. Sodium bicarbonate 
solution should be freely given by the mouth if the stomach will 
tolerate it. 



CHOLERA MORBUS 

This acute, painful, rapidly exhausting disorder arises from exposure 
to cold, the ingestion of poisonous or irritating foods, exposure to 
excessive heat, and a number of similar causes. 

In reality, it may be regarded in one instance as a gastroenteritis, 
and in another as an acute serous diarrhoea associated with much 
pain of a griping, rending character. Nothing compares to counter- 
irritation and morphine hypodermic ally for the purpose of affording 
relief. A large mustard or capsicum draft should be placed over 
the abdomen and allowed to remain as long as it can be borne. If 
the patient knows that he has taken irritant foods, \ ounce (16.0) of 
castor oil with 15 to 20 minims (1.0-1.3) of laudanum added to it, 
to prevent griping, should be employed to sweep out the offending 
masses before any other remedies are used, and be followed by an 
antidiarrhcea mixture, such as the following: 



CHOREA. 709 

3— Acidi sulphurici aromatiei f5jj vel Ifiv (8.0-16.0). 

Fluidextracti hsematoxyli f3ij (8.0). 

Spiritus chloroformi ....... f5ss (16.0). 

Syrupi zingiberis q. s. ad fgnj (90.0).— M. 

S.— Dessertspoonful (8.0) every two hours. 

If the pain is very severe, the patient should be given morphine 
(gr. i [0.015]) and 'atropine (gr. T io P.0004]) hypodermically. (See 
articles on Diarrhoea and Cholera, Asiatic.) 

CHLOROSIS. 
(See Anaemia.) 

CHOREA. 

St. Vitus' dance is a nervous affection, generally occurring in chil- 
dren, yielding to treatment quite readily in some cases, and in others 
remaining persistently severe, and even becoming worse, under the 
physician's care. 

The disease is always to be treated by the removal of all sources of 
reflex irritation, such as worms, a long prepuce if it is irritated by 
retained urine or smegma, or other trouble of this character, and in the 
avoidance of punishment or severe rebuke on the part of the attend- 
ants. This advice is given not because chorea is produced by such 
irritating conditions, but because they tend to impair the nervous 
tone of the patient. Except in that form of the disease closely associ- 
ated with or dependent upon rheumatism, the profession universally 
employs arsenic in one of its forms as a specific remedy. Generally 
Fowler's solution is used, and, unless the parents are intelligent enough 
to drop medicine carefully from a bottle or dropper, the physician 
should order a 3-ounce mixture (90.0) with 60 minims (4.0) of Fowler's 
solution, so that each teaspoonful will contain a little less than 3 
minims of the drug. Very frequently, to be effective, arsenic must 
be used in ascending doses, increased 1 minim (0.06) a day, and in 
consequence the dilution just spoken of is to be avoided, and the 
importance of care in measuring the pure drug impressed upon the 
patient's relatives. 

When arsenic is used the physician should instruct the attend- 
ants to stop administering the drug if any pufiiness under the eyes is 
seen in the morning on arising from bed, or if any pain in the bowels 
ensues, as these symptoms show that the full medicinal action of the 
drug is being felt. 

When arsenic fails, cimicifuga in the dose of 20 to 30 minims (1.3-2.0) 
of a fresh fluidextract for a child of ten years may be used as the next 
best remedy. 

When the disease is associated with rheumatism, recent or remote, 
large doses of the salicylates, particularly novaspirin, may be of value, 
and should be thoroughly tried. 



710 DISEASES. 

In some cases of chorea the muscular jerkings are so severe that 
sleep is impossible, and the patient has to be held in bed and the bed- 
covers tied down. These cases will often obtain a quiet night by the 
use of the hot pack at bedtime. (See Heat.) The child should be 
placed in a blanket previously dipped in water as hot as can be borne 
by the patient and thoroughly wrapped up in another (dry) blanket to 
retain the heat, and then be allowed to sweat. Care must be taken 
that a heat-stroke does not result, and, if sweating does not come on 
and oppression ensues, the blanket must be removed. The sheets 
should be ironed to have them warmed for the patient when she is 
returned to bed, and it is often better to let her sleep between dry 
blankets. The efficacy of this treatment is increased by the use of a 
dose of bromide of sodium or potassium and a little chloral, as fol- 
lows: 

3— Chlorali hydrati 3 j (4.0). 

Sodii bromidi 5ij (8.0). 

Aquae destillatae q.s.ad f Siij (90.0). — M. 

S. — A dessertspoonful (8.0) in water every five hours for three doses. 

In other instances, 3 to 5 grains (0.15-0.3) of medinal are advan- 
tageous. 

CHOROIDITIS. 

Choroiditis, or inflammation of the choroid, may depend upon con- 
stitutional disorders, infections, toxins and traumatisms, or upon dis- 
eases in other portions of the eye. Common varieties are syphilitic, 
tuberculous and traumatic choroiditis. Like iritis and iridocyclitis a 
number of types of acute choroiditis are caused by bacterial elements 
arising from local areas of sepsis especially in connection with the 
teeth, tonsils, nasal passages and nasal accessory sinuses. 

The treatment depends upon the recognition of the cause and suitable 
general and local medication. Mercury, iodides and alteratives, in 
general terms, are usually indicated; great care should be exercised to 
search for focal infections. Tuberculous choroiditis indicates the use 
of tuberculin in suitable cases. 

COLIC (HEPATIC). 

This exceedingly painful condition, due to the engagement of a 
gallstone in the bileTduct, is usually associated with faintness and 
nausea. 

The object of the physician must be to relieve the pain, not only 
by the use of anodynes, but also by aiding in the escape of the stone 
into the bowel. To relieve the pain a hypodermic injection of mor- 
phine, J to J grain (0.015-0.03), accompanied by ^ grain (0.0006) 
of atropine, is indicated. The morphine not only decreases the pain, 
but allays spasm, and the atropine relaxes the spasm of the muscular 
coats of the ducts and allows the stone to pass through the relaxed 



COLIC. 711 

passage-way. Hot applications, such as turpentine stupes, may be 
used over the liver, but relaxation is not to be obtained by the use 
of nauseating emetics, as the retching or vomiting may rupture the 
distended gall-bladder. Energetic rubbing should not be used for 
the same reason. 

For years the use of olive or cotton-seed oil has been largely 
resorted to in this affection, and while we are not sure of the manner in 
which it acts, the studies of Rosenberg and others point to the chang- 
ing of the oil into glycerin and fatty acids, the first of which liquefies 
and increases the flow of bile. Often the large dose of oil causes 
nausea, and this, by producing general relaxation, may aid in the 
escape of the stone. The oil is used during the attack of pain, and 
must be swallowed in the dose of half a pint at least; smaller quantities 
do not suffice. Its action may be aided and its retention in the stomach 
promoted by the addition of a drachm of ether to each dose. 

Shortly after the oil is swallowed sudden relief often occurs, due, 
perhaps, to the escape of the stone into the bowel. The stools should 
then be carefully watched for gallstones, but care should be taken 
that the lumps of soap which are passed, made from the oil by the 
alkaline juices in the intestines, are not mistaken for true biliary 
calculi. If the pain does not yield to morphine, chloroform or ether 
may be inhaled for the relaxation of the spasm and the relief of pain. 

In the endeavor to render our treatment of a patient with gallstones 
rational, we naturally study the causes which induce their formation 
and the manner in which we can expel those stones which have 
formed before the case has come under proper care, or in spite of any 
preventive measures which we may have attempted. Unfortunately, 
we are met at the very beginning of our study by the fact that the 
physiologist and the pathologist have not as yet discovered the exact 
characteristics of the general systemic conditions which underlie their 
formation; but, on the other hand, experimental and clinical studies 
have developed a number of facts which are of great value. Thus, 
we now know that there are a number of local causes which distinctly 
predispose to the formation of gallstone, and that these causes are 
commonly found in that very class in which the systemic tendency to 
stone-formation is most marked. In the first place, a catarrhal state 
of the biliary passages favors the formation of gallstone by providing 
an excess of mucin, with the aid of which the stone may be formed; 
secondly, this catarrhal state is commonly associated with, or produces 
of itself, a diminished alkalinity of the bile, whereby the cholesterin 
becomes more readily precipitated, and at the same time, it would 
appear, causes the deposition of an abnormal amount of lime salts, 
brought from elsewhere in the body and passed out through the mucous 
membrane. This latter fact seems proved by the circumstance that 
bile itself contains very little lime, and that more lime is found in 
stones lying against markedly catarrhal mucous membranes than in 
stones not so situated. Again, it sometimes happens that the nidus 



712 DISEASES. 

for a stone consists of agglutinated typhoid bacilli in the gall-bladder 
or duct. So far, then, we have a simple, pathological process pro- 
viding no less than three ingredients of stone-formation — namely, 
mucin, cholesterin, and stearate or some other salt of lime. There 
are still two other important factors at work — namely, the systemic 
state, gouty or otherwise, which tends to stone-formation, and the 
stasis of the bile in its ducts, because the catarrhal process in the 
mucous membrane blocks its passage toward the bowel. 

Recognizing these etiological factors, it now becomes our duty to 
oppose them, and we have the following indications to fulfil: 1. By 
causing a free secretion of bile to produce a rapid flow of fluid which 
shall be normally liquid and probably normal in its constituents. 
2. By the use of alkalies to antagonize the development of acid ten- 
dencies and to aid in the solution of mucus. 3. By regulating the diet 
prevent those hepatic and systemic disorders which tend to the forma- 
tion of stone. 4. As catarrhal states are often due to or aided by bac- 
terial infection, to produce intestinal asepsis as far as possible. 

The normal secretion and flow of bile are best brought about by 
exercise of a gentle and wisely directed nature, taken continually and 
regularly, and particularly those forms of exercise which call into play 
the abdominal muscles and diaphragm or cause hepatic movements. 
The chief and best of these is horseback riding, or, if the patient is 
too feeble for this, massage should be resorted to, the hypochondrium 
being well but gently kneaded and rubbed daily for a considerable 
period of time. If the liver seems very torpid, calomel in small divided 
doses of a fraction of a grain may be given several times a week, or 
nitrohydrochloric acid may be used. In other instances, where 
there is reason to believe that the flow is sluggish and the 
bile not sufficiently alkaline, and that catarrh and putrefactive ten- 
dencies are present, the administration of benzoate or salicylate of 
sodium, in 10- or 20-grain doses, will result in increasing the flow, 
increasing the alkalinity, overcoming the catarrh, and then arresting 
intestinal putrefaction. If the catarrhal process is very marked, 
chloride of ammonium will act even more satisfactorily. This treat- 
ment seems especially valuable when the stones that are passed are 
very dark in color, indicating that much pigment and little cholesterin 
is present. In respect to the use of alkalies, the patient should drink 
freely of those mineral waters which will provide alkaline substances, 
such as Contrexeville, Vichy, and Kronenquelle, and it is useful in 
many such cases to relieve any tendency to constipation or duodenal 
catarrh by the administration of hot Carlsbad water before breakfast 
daily. 

In the matter of regulating the diet, all rich or fatty foods are to be 
prohibited. Meat should -be used in moderation, no game ingested, 
and green vegetables largely eaten. 

The catarrhal condition, associated with marked bacterial infection, 
as may be evidenced by some febrile movement, is best controlled by 



CONJUNCTIVITIS. 713 

the use of turpentine, chloroform, and ether, given internally, and 
accompanied by the application externally of hot poultices to the 
hepatic area. These poultices may or may not be fortified by mustard, 
and when removed should be replaced by a warm pad to prevent 
chilling of the surface of the body. 

Of the internal remedies just named, turpentine is the most useful, 
since it liquefies mucus, aids the flow of bile, and is thought by some 
physicians to cause expulsion of the stone by stimulating the walls 
of the ducts, .and to dissolve the stone. The latter action is impos- 
sible. Nevertheless, its continual use seems to prevent the formation 
of stone. Ralfe states that it is best given as follows: 



1^ — Olei terebinthinae .... 

Syrupi acaciae 

Sodii phenolsulphonatis 
Spiritus setheris compositi 
Aquae menthae piperita? 
S. — To be taken twice or thrice a day. 



. Tib' (0.30). 

. fgss (16.0). 

. gr. xx (1.30). 

. Nl-xv (1.0). 

q.s. f §j (30.0).— M. 



We would prefer adding compound tincture of lavender instead of 
peppermint-water. If this mixture cannot be retained by the stomach, 
the turpentine may be given in capsule, and followed by a draught of 
milk. 

If attacks of gallstone colic are frequent enough to incapacitate the 
patient, or if pain and tenderness in the region of the gall-bladder is 
severe or constant, surgical relief is demanded. 

Finally, a most important factor in the prevention of gallstone 
formation in susceptible persons is the avoidance of exposure and wet, 
and, if possible, residence in a sunny climate during winter months. 



CONJUNCTIVITIS. 

Simple Conjunctivitis, sometimes called catarrhal, acute, or muco- 
purulent ophthalmia, is characterized by congestion of the conjunctiva, 
loss of transparency of the palpebral portion, and some dread of light, 
with a discharge, sufficient only to glue the lids in the morning, or free 
and mucopurulent. In the milder stages the use of a boric-acid 
lotion (10 grains to the ounce [0.60:30.0]) is suitable, and the lids 
should be frequently washed with neutral soap and water; if there 
be much mucopurulent discharge, the lid should be everted and an 
application made of a solution of nitrate of silver (from 2 to 5 grains 
to the ounce [0.12-0.30:30.0]). If the discharge becomes profuse, 
bichloride of mercury, 1 : 10,000 may be employed with advantage 
and the nitrate-of-silver solution increased 10 grains to the ounce 
(0.60-30.0), the excess being neutralized with a solution of salt or 
washed away with tepid water. In place of nitrate of silver pro- 
targol and argyrol are much used, and may be employed in a strength 
varying from 10 to 25 per cent., according to the severity of the 



714 DISEASES. 

symptoms. Much inflammatory reaction in this disease may be 
alleviated by iced compresses. Patients suffering from catarrhal con- 
junctivitis should be protected from tobacco-smoke, bright light, dust, 
or any mechanical irritant. Atropine usually is unnecessary unless 
a corneal ulcer - complicates the affection. The patient may wear 
smoked glasses, but in no circumstances should the eyes be bandaged 
or have poultices applied to them. Domestic medication of this 
sort may change a simple conjunctivitis into a serious and purulent 
inflammation. Topical medications other than those mentioned are 
biborate of sodium (gr. iv-viij to the ounce), alum (4 to 8 grains to the 
ounce [0.25-0.5:30.0]), sulphate of zinc (1 to 2 grains to the ounce 
[0.06-0.12:30.0]), which may be suitably combined with boric-acid 
solution. During the subsidence of the inflammation, and if it shows 
any tendency to become chronic, the application of an alum crystal or 
a solution of tannin and glycerin (10 grains to the ounce [0.60:30.0]) is 
suitable. It should be remembered that mucopurulent conjunctivitis 
may become epidemic in crowded institutions, and great care should 
be taken to isolate cases. One soiled towel may be the source of 
infection to a great number of children. Constitutional treatment 
ordinarily is not required, but proper hygiene, fresh air, good food, 
the intelligent use of laxatives, and tonic doses of quinine are useful. 
Conjunctivitis may be associated with nasal catarrh, bronchitis, a 
general cold, eczema of the face, and the exanthemata. 

Acute contagious conjunctivitis, vulgarly known as "pink eye," 
does not greatly differ in its manifestations from ordinary simple con- 
junctivitis, except that it is more violent and is more apt to be associ- 
ated with hemorrhages beneath the conjunctiva. As its name indicates, 
it is highly contagious, and sometimes appears in an epidemic form. 
It is due, in the great majority of instances, to the Koch- Weeks bacil- 
lus. A very similar form of epidemic conjunctivitis is caused by the 
pneumococcus, and sometimes by the influenza bacillus. The treat- 
ment is the same as that already described. A solution of sulphate 
of zinc, 1 or 2 grains to the ounce, is preferred by some surgeons. 

Conjunctivitis due to the Morax-Axenfeld bacillus, although usu- 
ally subacute in character, may appear as an acute manifestation. 
Solutions of sulphate of zinc (gr. i-iv to foj) (0.05-0.2-30) are prac- 
tically specific in their action in this disease; the silver salts are of 
no use. 

Burns of the Conjunctiva. — Immediately after the accident all foreign 
particles should be removed; then a few drops of sweet oil may be 
instilled and atropine employed (suitably incorporated with liquid 
vaselin) to prevent iritis. The chief danger lies in the development of 
severe corneal inflammation and symblepharon ; the latter may some- 
times be prevented by daily breaking up the granulation-tissue or by 
the insertion of a piece of goldbeaters' skin between the inner surface 
of the lids and the eyeball. The associated conjunctivitis and keratitis 
require treatment differing in no way from that described in connection 
with other forms of these affections. 



CONJUNCTIVITIS. 715 

Purulent Conjunctivitis occurs in three specific forms: In the new- 
born (conjunctivitis neonatorum, or ophthalmia neonatorum), in young 
girls (gono-blennorrhcea of young girls), and in adults (gonorrhceal 
conjunctivitis, or ophthalmia). 

Conjunctivitis neonatorum is caused by the introduction into the 
eye of infecting material from some portion of the genito-urinary 
tract of the mother, at the time of or shortly after birth. The majority 
of cases, and all severe forms, are associated with a special micro- 
organism, the gonococcus of Neisser, and the secretion in the eye of 
any fiew-born child should always be promptly examined bacterio- 
logically. The prognosis is always grave in gonorrhceal cases, but with 
competent medical attendance, and if the eye comes under treatment 
while the cornea is still clear, except in certain types, with inherent 
malignancy, or where depreciation of nutrition or intercurrent illness 
dimmish the resisting power of the child, the disease should be brought 
to a successful termination. Failure to check the disease or any 
neglect in its management may result in severe corneal ulceration 
and its sequels — leukomas and staphyloma. Conjunctivitis neo- 
natorum is the cause of about 8 to 10 per cent, of the total number of 
cases of blindness in this country. Fully 25 per cent, of the inmates 
of asylums for the blind have lost their sight from this disease. In 
order to remove the discharge, the lids should be gently separated and 
the conjunctival sac irrigated with a saturated solution of boric acid, 
and this irrigation repeated as frequently as is necessary to free the 
conjunctival sac from purulent secretion. To check the discharge 
nitrate of silver may be applied to the everted lids once a day by means 
of a cotton mop in a strength of 2 per cent., and its excess neutralized 
with a physiological salt solution. The application of white vaselin 
to the edges of the lids is useful as a protecting agent. Because of its 
irritating qualities, and because skilled hands are not always to be 
commanded in this disease, nitrate of silver has in recent times been 
largely substituted with argyrol and protargol. Of the former remedy, 
a 25 per cent, solution should be dropped freely into the conjunctival 
sac, so that the surfaces of the inflamed conjunctiva are kept con- 
stantly bathed in the fluid. (See Immersion Method.) Argyrol is 
practically without bactericidal properties, but is bland, and has the 
property of floating to the surface the mucus and pus, and thus render- 
ing their removal easier than would otherwise be the case. If this 
does not check the discharge, its action should be supplemented by an 
application of nitrate of silver in the manner already described, great 
care being taken not to injure the cornea and therefore the applica- 
tions should be made by the physician himself or by a trained nurse. 
In place of argyrol, protargol in 10 per cent, solution may be sub- 
stituted, but it is more irritating than argyrol and not superior in 
any respect to nitrate of silver. The application of cold compresses 
during the early stages is often most useful, but it requires much 
experience to determine whether cold should be used, and not all cases 



716 DISEASES. 

are suited to its employment. Atropine drops (0.5 per cent.) twice a 
day may be used if corneal ulcer results. Recently frequent irrigations 
with ice-cold normal salt solution has been recommended. (Heckel.) 
About 25 per cent, of the cases of conjunctivitis neonatorum are due to 
micro-organisms other than the gonococcus, chiefly the pneumococcus, 
and require the treatment already detailed in the section devoted to 
non-gonorrheal conjunctivitis. 

The prophylaxis of ophthalmia neonatorum is best secured by the 
employment of the method which was instituted by Crede, namely: 
As soon as the head of the child is born, the lids are carefully cleansed, 
parted, and two drops of a 2 per cent, solution of nitrate of silver are 
instilled into each conjunctival sac. Small cold compresses are then 
laid upon the lids and renewed at suitable intervals. This method 
should be employed in all infected cases and in cases from which 
the suspicion of infection has not been removed, but it is unnecessarily 
severe if previous examination has demonstrated the entire absence 
of infection. Under the last-named conditions careful cleansing of 
the lids of the eye and flushing of the conjunctival sac with a mild 
antiseptic lotion are sufficient. Neither protargol nor argyrol is a 
suitable substitute for nitrate of silver in infected cases, but it is safe 
to reduce the strength of the nitrate of silver solution to 1 per cent. 

Gonorrheal conjunctivitis of adults, provided the patients are 
robust and the cornea unaffected, should be treated in the early 
stages by the application of iced compresses, either constantly, or 
else for twenty minutes at a time every two or three hours. Usually 
their application is inadvisable after the first thirty-six hours. Great 
care should be exercised in removing the quickly accumulating dis- 
charge in the manner already described, and this removal is facil- 
itated by keeping the conjunctival sac immersed in a 25 per cent, 
solution of argyrol. This drug, however, is in no sense a specific, 
and its action should be supplemented by a daily application of nitrate 
of silver, in the manner already described, and in the same strength. 
In place of argyrol, protargol, in 10 to 20 per cent, solution, may be 
employed in the same manner as the argyrol, and in the experience 
of some clinicians has proved of greater value than the argyrol, or 
than the argyrol plus the nitrate of silver. In the writer's experience 
however, nitrate of silver, either with or without the addition of 
argyrol, remains the sovereign remedy. In certain severe cases, follow- 
ing the recommendation of Kalt, the disease may be treated with copious 
irrigations of permanganate of potassium, 1 : 5000, four or five times 
a day, and in suitable cases this furnishes excellent results. Always, if 
there is corneal involvement, which is only too apt to occur, and even 
before its appearance, atropine should be used with sufficient frequency 
to keep the pupil dilated and to reduce the hyperemia of the iris and 
ciliary body. Scarification of the chemotic ocular conjunctiva has been 
recommended, but must be practised with great care lest the cornea be 
injured. The prognosis is much more grave in this disease than in 



CONJUNCTIVITIS. 717 

ophthalmia neonatorum, and in a very large percentage of the cases, 
even under the best treatment, corneal ulcers and consequently corneal 
scars and even staphyloma are the result. 

Occasionally young girls are the subjects of vaginitis, which in severe 
form is associated with a purulent discharge, and in hospitals and 
asylums has occasionally assumed the form of an epidemic. In some 
of these cases gonococci are present in the discharge. The treatment 
should in all respects conform to that which has been described in 
connection with ophthalmia neonatorum. 

Chronic Conjunctivitis may result from an antecedent acute inflam- 
mation of the conjunctiva or exist as an independent affection, espe- 
cially in elderly people, in whom it sometimes becomes a troublesome 
symptom, especially if complicating cataract. The characteristic 
lesions are roughness of the papilla? of the conjunctiva, swelling of the 
caruncle, and soreness of the angles of the eyelids. There are no 
granulations, although the disease is sometimes inaccurately spoken 
of as granular lids. A soothing lotion is indicated (10 grains of 
boric acid to the ounce [0.6 : 30.0] of water), to which may be 
added -1 grains (0.12) of biborate of soda and for which a similar boric- 
acid lotion with -1 grains (0.25) of salt to the ounce (30.0) may 
be substituted. A very suitable local application is lapis divinus (sul- 
phate of copper 1 part, alum 1 part, nitrate of potassium 1 part, fused 
together, and camphor equal to one-fiftieth of the whole added; the 
mass is run into sticks, and the application made to the everted 
lid. Other useful applications are tannin and glycerin (10 grains 
[0.6] to the ounce [30.0]) and alum crystal. If refractive error exist, 
this should be corrected. It is to be remembered that chronic con- 
junctivitis distinctly contraindicates any operative interference in 
the eye, as, for instance, cataract extraction. There is an interesting 
form of chronic conjunctivitis, or, more accurately, subacute con- 
junctivitis, which runs a course lasting from eight weeks to several 
months, and which is characterized by very slight objective symp- 
toms, due to the presence of the diplobacillus of ATorax and Axenfeld, 
and which is promptly cured by the application of a solution of sulphate 
of zinc, 1 or 2 grains to the ounce. The conjunctival secretion of stub- 
born cases of conjunctivitis should always be examined for this bacillus. 

Lachrymal Conjunctivitis is a name given to a chronic form of in- 
flammation of the conjunctiva associated with obstruction in the 
lachrymal duct, and characterized by a tear-soaked appearance of the 
eye, small pustules at the roots of the lashes, and a gummy discharge 
along the palpebral margin. This can be cured only by relief of the 
stricture of the nasal duct which causes it, but may be alleviated with 
the same remedies recommended in the treatment of chronic con- 
junctivitis. 

Follicular Conjunctivitis — a disease sometimes mistaken for granu- 
lar lids, but having a distinct clinical difference, inasmuch as the 
swollen follicles are absorbed without the production of cicatricial 



718 DISEASES. 

changes in the conjunctiva — requires for its local treatment weak 
astringents and antiseptic lotions, and the application to the swollen 
follicles of an ointment of sulphate of copper (gr. \ to the drachm 
[0.03 : 4.0]). If the disease is stubborn, the swollen follicles should be 
crushed with suitable expression forceps. 

The disease, or one analogous to it, is sometimes produced by the 
prolonged instillation of atropine, and less frequently by eserine and 
cocaine. If this is its cause, the drug must be suspended and the 
surface painted with an alum crystal. 

Granular Conjunctivitis. — This disease is characterized by an inflam- 
mation of the adenoid layer of the conjunctiva, associated with the 
development of the trachoma bodies or granulations and enlargement 
of the papillary layer. After absorption and metamorphosis of the in- 
flammatory material, cicatricial changes develop and the disease may 
be complicated with distortion of the lid, incurvation of the lashes, 
and ulceration and bloodvessel formation in the cornea (pannus). In 
the early stages the enlarged follicles, or trachoma bodies, are chiefly 
located in the retrotarsal folds, are of a grayish-white or yellowish 
color, and they have been compared to frog-spawn owing to their 
appearance. Later they are hidden by the swollen conjunctiva and 
changed in appearance by the metamorphosis of their contents, which 
has already been noted. In certain stages the disease, especially if 
associated with purulent secretion, is markedly communicable, and 
is therefore notably dangerous in schools, camps, cantonments and in 
any institution where large numbers of inmates are gathered together. 
Its detection by those who inspect immigrants is of the utmost impor- 
tance, in order that its spread may be limited. If the disease is asso- 
ciated, as is often the case, with a mucopurulent secretion, the con- 
junctival sac should be frequently cleansed with a saturated solution 
of boric acid, or with a solution of bichloride of mercury, 1 : 8000, or 
cyanide of mercury, 1 : 5000, and nitrate of silver, or argyrol, or pro- 
targol may be employed to check the purulent discharge, care being 
taken that the applications are not too prolonged lest they cause stain- 
ing of the conjunctiva. After the discharge has been checked, or in 
those cases in which it does not exist, the everted lid may be touched 
with a crystal of sulphate of copper, or with a solution of tannic acid, 
30 grains to the ounce of glycerine, or with one of boroglyceride, 20 to 
50 per cent. In place of sulphate of copper, copper citrate in 5 per cent, 
ointment, introduced into the conjunctival sac with the aid of gentle 
massage, is of service. A 5 per cent, solution of sulphate of copper in 
glycerine is useful. Numerous other antiseptic and astringent remedies 
have been employed, namely, phenol, hydrastin, iodide of silver, ich- 
thargon, 2 to 3 per cent., ichthyol, and, indeed, almost any remedy of 
this nature whose application is suited to the ocular surroundings. 

The best results, however, are obtained by surgical measures, the 
mildest of which consist in some form of expression operation, by 
means of which the trachoma bodies are squeezed with suitable forceps 



CONJUNCTIVITIS. 719 

from their lodging place in the conjunctiva, and the lids subsequently 
treated according to the principles already enunciated. Their removal 
by vigorous rubbing with the end of the fingers covered with surgical 
gauze is performed by some surgeons. Other surgical procedures 
consist in scarification, followed by brushing of the conjunctiva with a 
solution of bichloride of mercury, 1 : 2000, electrolysis, and excision 
of the fornix conjunctivae and in chronic cases of the tarsal plate. 
X-rays and radium are recommended by some surgeons in the treat- 
ment of trachoma, but suitable surgical procedures produce the best 
results and if properly applied cure a large percentage of cases. 

Vernal Conjunctivitis (Fruehjahr's Catarrh), characterized by photo- 
phobia, mucous discharge, granulations in the palpebral conjunctiva, 
and a hypertrophy of the tissue about the limbus, appears chiefly in 
the warm months and disappears in cold weather. The usual treat- 
ment of conjunctivitis is suitable, and the various measures described 
in connection with trachoma have been tried; but protection from 
heat and change from a warm to a colder climate are most likely to 
meet with success. The persistent use of adrenalin chloride (1 : 10,000) 
is useful. Abbe recommends radium. The .r-rays have been tried. 

Diphtheritic Conjunctivitis may appear alone or in association with 
diphtheria of the throat and nose. The initial subjective symptoms 
are those of purulent ophthalmia; the characteristic objective symp- 
toms, a board-like infiltration of the lids with a deposit of gray mem- 
brane upon the palpebral conjunctiva. More than in any other eye 
disease destructive inflammation of the cornea is threatened. In the 
early stages the eye should be frequently cleansed with boric acid or 
bichloride of mercury solution, and atropine drop should be instilled. 
The constitutional measures for diphtheria are necessary, and the best 
treatment is the employment of injections of diphtheria antitoxin. 

Chemosis of the Conjunctiva, in which this membrane is infiltrated 
with serum, is usually a symptom of other ocular disorders, and sub- 
sides under the general treatment directed to their relief. It is a 
common sign of diseases of the nasal accessory sinuses. Angioneurotic 
edema of the conjunctiva may appear without apparent cause and 
with marked suddenness. Good results may follow nicking the swollen 
tissues with a pair of scissors, the application of a warm, moist com- 
press, and the use of astringents, especially alum. 

Hemorrhage beneath the Conjunctiva (subconjunctival ecchymosis) 
may follow an injury, occur during a paroxysm of whooping-cough, 
and occasionally, in elderly people, may appear spontaneously. Recur- 
ring subconjunctival hemorrhages in elderly people are indicative in 
many instances of renal disease, having much the same significance as 
hemorrhages in the retina. Xo treatment materially hastens absorp- 
tion of the blood, unless it be massage of the globe through the 
closed lid; any associated conjunctival irritation indicates a boric acid 
collyrium. 



720 DISEASES. 



CONSTIPATION. 



This troublesome state depends on a number of causes, the most 
common of which is the following of a sedentary life, devoid of 
the exercise intended to keep the intestinal and hepatic secretions 
in an active state. Another frequent cause is simple laziness, which 
causes the patient to resist the call of the bowel for evacuation until 
this part of the body becomes indolent and atonic, while modesty 
often causes constipation in females, because a woman prefers to 
suffer rather than go to a closet which may be somewhat publicly 
situated. In other instances it is due to enteroptosis, or depends 
upon deficient nerve-supply or muscular weakness and lack of secretion 
in the lower bowel, or upon hepatic torpor. When due to enter- 
optosis, which is more commonly met with in multipara or in stout 
women who have grown thin, abdominal support should be given by a 
belt which holds up the abdominal contents or by adhesive straps. 

Whatever the causes are, they should be sought for, and, if possible, 
removed, the physician not being content to order purgatives, which, 
while they may give temporary relief, soon lose their power. 

Further than this, it must be remembered that hygienic measures 
always take first place in the method of treatment, and, if possible, 
drugs should occupy a very secondary role. Particular attention 
should be paid to diet, and the physiology of peristalsis must be well 
borne in mind. 

It has been proved by a large number of studies, both in the normal 
intestine and by the use of purgatives, that peristalsis is almost entirely 
a reflex action depending for its existence upon the integrity of the 
nervous plexuses in the intestinal walls— namely, those of Auerbach 
and Meissner — the first of which are situated between the longitudinal 
and circular muscular fibres which they supply, the latter existing 
in the submucosa and supplying the walls of the villi, the glands of 
Lieberkiihn, and the small arteries and venules. 

It has also been found that the vagus nerve, when stimulated reflexly 
or directly, increases peristalsis, and that moderate stimulation of the 
splanchnic nerve decreases it. 1 It at once becomes evident that any 
decrease in the normal activity of these nerves and nerve-centres 
must speedily result in constipation, and the costive condition conse- 
quent upon hepatic torpor is due to the fact that the intestinal walls do 
not receive the proper stimulation from the bile te set in motion a 
reflex peristaltic wave, the result of which will be evacuation. This fact 
rests upon the results of direct experiments, which prove the bile 
to be primarily an intestinal stimulant, antiseptic, and promoter of 
secretion. 

Other series of experiments have shown that the circulation of the 

1 Some persons believe that Meissner's plexus receives impulses from the walls of the 
intestine and transmits them to the motor plexus of Auerbach, which then sets in motion 
peristalsis. 



CONSTIPATION. 721 

blood through the intestines greatly influences peristalsis, and disorders 
in the blood-supply readily bring on intestinal disorder. 

The deductions to be drawn from these facts are many. In the 
first place, it is evident that the maintenance of an active, normal 
circulation of blood in the abdomen and a free pouring out of bile 
from the liver and gall-bladder are necessary to a healthy peristalsis; 
and we find that, aside from drugs, there are a number of remedial 
measures which may be resorted to according to the means of the 
patient. By far the best of these is horseback exercise for at least an 
hour a day or every other day, which by the motion actively stirs up 
and excites the abdominal viscera as no other measure can do. If for 
any reason horseback exercise is impossible, then abdominal massage, 
carried out by a capable "rubber," is to be tried, the hands following 
more particularly the course of the ascending, transverse, and descend- 
ing colon, the kneading movements being also applied to the hypo- 
chondriac regions. If neither of these measures can be used, then 
the patient must resort to those gymnastic movements which involve 
the abdominal muscles, either by the use of dumb-bells or pulleys, 
such as are sold under the name of "home gymnasiums," or by bend- 
ing the body forward, backward, and laterally, with the fists pressed 
into the hypogastrium. 

At the same time that these measures are directed the diet of the 
patient must be so regulated that the food shall contain a large amount 
of residue — that is, after digestion enough of the husk of the grain or 
enough vegetable fibre must be left free in the intestines to form a 
stimulus to the intestinal wall as it slips over the mucous membrane. 
If a meat diet is largely used, so little residue is left after digestion 
that constipation ensues, but if vegetables are largely eaten, the reverse 
is the case. No better evidence of this can be adduced than the hard, 
clay-like passages of the dog and the soft passages of the cow. Very 
often a plateful of cracked wheat (wheaten grits) eaten at breakfast 
each morning, or the use of bran bread, will relieve a tendency to chronic 
constipation. In these cases milk as a prominent article of diet is 
to be avoided above all things, since it is almost entirely assimilated 
and leaves no residue, though it supplants other foods. Green or 
canned corn is of great service. Fruits do good in constipation in 
one of two ways — they contain either residual materials or sufficient 
vegetable acid salts to be laxative. Figs, by reason of their many 
small seeds, which scrape the mucous membrane during peristalsis, 
are particularly valuable, and apples, prunes, dates, and tamarinds are 
all useful. Agar-agar is useful and liquid petrolatum of the heavy type 
is beneficial when the stools are dry, as it acts as a lubricant and keeps 
the stools soft. It must be remembered that strawberries, raspberries, 
and blackberries are generally constipating rather than purgative. 
In regard to drink, nothing is so good as a glass of cold water taken 
on arising in the morning or just before breakfast, or, if the cold can- 
not be borne, then a glass of as hot water as can be swallowed with 
46 



722 DISEASES. 

comfort may be substituted. Coffee is constipating to most persons, 
largely because of its empyreumatic oil, and tea has the same tendency 
because of its tannic acid. Brandy, as every one knows, is distinctly 
constipating, and whisky possesses so little power to the contrary as 
to be devoid of influence in either direction. Beers differ in their 
properties, some of them increasing and some of them decreasing 
intestinal activity. 

The patient suffering from constipation should go to stool regularly 
after breakfast every day even if the attempt is abortive, and so train 
the bowel to having a movement at this time. 

The use of drugs for the relief of constipation is capable of division 
into two parts: First, the employment of remedies to unload the bowel, 
which has become filled; second, the use of drugs which will so influ- 
ence the intestines as to cause evacuation and produce normal activity, 
or, in other words, drugs which will cure the tendency instead of 
giving temporary relief. Of the first class we find the various pur- 
gative salts, jalap, colocynth, senna, mercury, castor oil, and rhubarb; 
of the second class, aloes, cascara sagrada, phenolphthalein, rhamnus 
frangula (buckthorn), phosphate of sodium, and small doses of podo- 
phyllin. The physician should bear in mind that defecation is a nor- 
mal physiological act which must be continued all through life, and it 
is almost as foolish to stimulate the bowel continuously to peristalsis 
as perpetually to employ heart stimulants or respiratory excitants. 

Although habitually employed by many persons in daily doses, 
the purgative salts if given in concentrated form are exceedingly 
harmful in such instances, rapidly losing their power and decreasing 
the patient's strength by the abstraction of liquids and salts from the 
blood. They often produce ansemia when constantly used. These 
salines are to be employed simply to unload the bowel when an excess 
of fecal matter has accumulated or when irritant materials are to be 
swept out of the alimentary canal. In some cases of pelvic conges- 
tion associated with constipation magnesium sulphate may be given 
by enema in the proportion of 2 ounces (60.0) of the salt, 1 ounce 
(30.0) of glycerine, and 4 ounces (120.0) of water. In other instances, 
particularly where plethora exists, a course of Hunyadi water, Pluto 
water, Abilena, or other waters, which depend chiefly upon mag- 
nesium and sodium sulphate for their activity, is of service. When 
used habitually they should be diluted with hot water and given 
half an hour before breakfast. The patient should then take some 
exercise before taking food. Jalap, colocynth, and senna are not to 
be used constantly, as they are too active and the reaction from 
their effects causes constipation. Rhubarb is commonly used, but is 
of its class peculiarly unfitted to its task. Although it purges, it is 
distinctly astringent, and is therefore constipating afterward. 

Mercury is exceedingly harmful if used continuously as a purge, and 
may be the cause of much ill health, of decayed teeth, and of digestive 
troubles. Castor oil is notorious for its tendency to cause ultimate 



CONSTIPATION. 723 

constipation. It is to be used to clear out the bowels and not be 
employed continuously. 

Of the curative class of laxatives none compares to cascara sagrada, 
particularly in the form of the aromatic fluidextract or cascara cordial. 
Originally this drug, as prepared, was very bitter, but it is now made 
almost tasteless by certain manufacturers. This is the only drug 
which alone moves the bowels and at the same time tends to make 
future passages more easy and regular; the dose is 10 to 40 minims 
(0.60-2.60) of the fluidextract or 1 to 6 drachms (4.0-24.0) of the 
cordial. There is almost no griping produced by it. For regula- 
tion of the bowels of young children, particularly if the case have a 
tendency to rickets, phosphate of sodium in the dose of 5 to 10 grains 
(0.30-0.60) in milk is a useful laxative, and the same salt may be used 
in 30- to 60-grain (2.0-4.0) doses in adults. Phenolphthalein in the 
dose of 1 to 2 grains (,0.06-0. 12j, taken at night, is an excellent lax- 
ative. The two remaining drugs of this class, aloes and podophyllin, 
should always be used in combination with other non-purgative drugs, 
as is seen in the following formulae: 

1$ — Aloes purificati gr. xx vel xl (1.3-2.6). 

Extract! nucis vomicae gr. iv (0.25). 

Extracti physostigmatis gr. iij (0.20). 

Extracti belladonnae gr. iv (0.25). — M. 

Fiant pilulse No. xx. 

S. — One pill at night or night and morning. 
Or, 

I£— Resinse podophylli gr. ij vel iv (0.12-0.25). 

Extracti nucis vomicae gr. iv (0.25). 

Extracti physostigmatis gr. iij (0.20). 

Extracti belladonnae . . . . . . gr. iv (0.25). — M. 

Fiant pilulae No. xx. 

S. — One pill night and morning. 

The object of using several of these drugs is seen at a glance. The 
nux vomica acts as a bitter tonic and stimulant, and prevents sub- 
sequent atony of the mucous membrane, as well as increases reflex 
action, and consequently improves peristalsis; the physostigma is a 
tonic to the unstriped muscular fibre and gives it strength ; the bella- 
donna aids peristalsis by depressing the inhibitory fibres of the splanch- 
nic nerves, by allaying spasm, and by decreasing griping. In using 
these drugs, aloes and podophyllin, it should be remembered that aloes 
is slow and acts particularly on the lower bowel, and that podophyllin 
is the slowest in the list of purges. (See Phenolphthalein.) 

In obstinate constipation we are sometimes forced to resort to the 
compound cathartic pill of the U. S. P., or its modified form known as 
the Pilula Cathartica Vegetabilis (see Colocynth). After the bowels 
have been well emptied by this pill we can often regulate them by 
cascara sagrada with or without other laxatives, and by prescribing 
a proper diet and exercise. 

In the flatulence of old persons associated with constipation a little 
asafcetida or capsicum should be added to the pill of aloes just named. 



724 DISEASES. 

In some instances constipation arises from reflex irritation as from 
ovarian or bladder trouble or from chronic lead poisoning. This 
form of constipation may resist all purgatives and yield to opium or to 
tobacco, which quiet reflex action. In patients with enteroptosis con- 
stipation the use of a supporting belt is often of great service. 

The employment of enemata as a routine practice is to be discour- 
aged. In cases where it is necessary to use them for temporary relief 
and to get rid of flatulence, a little soap, common salt, or a few drops 
of turpentine may be added to the water. 

The injection of glycerin (1 to 2 ounces [30.0-60.0] ) has been 
largely resorted to, either pure or diluted one-half, and this method 
has been improved upon by the use of glycerin suppositories con- 
taining many drops of the drug. Glycerin acts in these cases as 
an irritant to the mucous membrane, and causes secretion by this 
means and by its abstraction of water from the tissues by reason 
of its hygroscopic powers. It is capable, however, of causing a good 
deal of rectal irritation in some persons. 

Much has been written on auto-intoxication resulting from constipa- 
tion, and radical surgical operations resorted to for relief. I heartily 
endorse these words of Woolley: 

1. Absorption of bacteria and other substances from an unhealthy 
bowel may produce serious symptoms. 

2. A surgical operation for intestinal stasis is not justifiable except 
as a last resort. 

3. There is no definite information in the literature to show that 
surgical procedures, made for intestinal stasis, have been more success- 
ful than medical (including hygienic) ones. 

4. Many cases in which symptoms are attributed to intestinal stasis 
are suffering from focal infections entirely outside the intestinal tract. 
Such infections are illustrated by pyorrhoea alveolaris, chronic tonsillar 
infection, and chronic infections of the antra and sinuses of the head. 

CORNS. 

These troublesome formations are best treated by the use of sali- 
cylic acid, the following formula being applied night and morning for 
several days, after which the part should be well soaked in hot water, 
when the entire corn will readily come away, but in some cases several 
attempts will be necessary : 

3— Acidi salicylici gr. xxx (2.0). 

Extracti cannabis gr. x (0.60). 

Collodii f 3ss (16.0).— M. 

S. — Apply with a camel-hair brush. 

The same acid may be used in alcohol, and lactic acid in the same 
proportion is often of service. 

In the so-called "soft corns," with much inflammation, the foot 
should be washed and dried, and a saturated solution of nitrate of 



CORYZA. 725 

silver, 60 grains (4.0) to 2 drachms (8.0) applied to the part every 
four or five days. 

CORYZA (ACUTE). 

The treatment of coryza of the acute variety, the form which most 
frequently presents itself to the physician for relief, is followed in many 
instances by such marked amelioration of the symptoms and shorten- 
ing of the attack as to encourage medical interference. It must be 
remembered, however, that the duration of the condition before the 
patient presents himself has much to do with the prognosis, for if the 
tissues of the nasal chambers have become boggy and swollen with 
exudate recovery must be more delayed than if remedies are applied 
in the early stages of the catarrhal process. The local treatment con- 
sists in the following measures for relief: By means of a medicine- 
dropper or an atomizer a few minims of a 4 per cent, solution of cocaine 
are dropped into the nostrils, the patient's head being well tipped back. 
If there is any contraindication to cocaine, adrenalin 1 : 10,000 may 
be used in many cases. After the constringing influence of the 
cocaine has shrunken the congested mucous membrane, so that the 
patient can draw air through the nostrils, the nasal chambers should 
be washed clean of mucus by means of the following lotion in an 
atomizer. 

1$ — Sodii chloridi . . . . . . . , . . gr. xv (1.0). 

Acidi borici gr. x (0.60). 

Sodii boratis gr. x (0.60). 

Aquae destillatse foiij (90.0).— M. 

The parts being thoroughly cleansed, a fine spray of the following 
should be used as antiseptic, sedative, anaesthetic, and protective: 

I$— Mentholis gr. viij (0.5). 

Camphorse gr. v (0.3). 

Petrolati liquidi . f 5j (30.0).— M. 

In this prescription the menthol exerts an anaesthetic effect, and pro- 
longs the constriction of the parts produced by the cocaine, so avoiding 
the secondary capillary dilatation due to that drug. The camphor 
exercises its well-known soothing influence, and the albolene protect? 
the membrane from dust and irritants. It is well to use a solution of 
antipyrine 2 to 4 grains to the ounce (0.12-0.25:30.0) of water as 
spray to prolong the effect of the cocaine. The albolene spray should 
follow, not precede, the antipyrine as the oil would prevent the anti- 
pyrine from acting. Under no circumstances should the antipyrine be 
used without the cocaine preceding it, as the pain is too severe. 

The internal treatment consists, in the very beginning of the attack, 
of the use of the formula for this purpose composed of belladonna, 
camphor, and quinine, and recommended in the article on Camphor. 
Much benefit often follows the use of 30-grain doses (2.0) of sodium 



726 DISEASES. 

bicarbonate every two hours for three doses. A hot foot-bath, with 
mustard in it, and the taking of a hot drink, such as lemonade with 
whisky in it, on going to bed, are useful. Often 20 or 30 minims 
(1.3-2.0) of sweet spirit of nitre added to this drink will increase its 
diaphoretic effect. In other cases, particularly in strong, hearty men, 
5 to 10 grains (0.3-0,60) of Dover's powder at bed-time will be better 
In still other cases Tully's powder, made with codeine instead of 
morphine, is very successful. 

This line of treatment is of little value after secretion has been fairly 
established, and in its place supportive measures are indicated. Small 
tonic doses of quinine, 2 to 4 grains (0.12-0.25) three times daily, some- 
times combined with the use of 5 to 10 grains (0.3-0.60) of chloride 
of ammonium, as prescribed in the article on Bronchitis, are useful. 
Where much headache is present full doses of the bromide of potas- 
sium or sodium are to be given, and the spray treatment already 
named for the purpose of cleansing the nasal chambers is to be per- 
sisted in while the attack lasts, but the cocaine ought not to be employed 
at this time unless absolutely needed. (See Camphor.) 

CROUP. 

(See Diphtheria.) 



CROUP (SPASMODIC). 

As this is a spasm of the glottis depending for its causation upon 
catarrh of the mucous membrane of the larynx, and as it is due most 
commonly to some reflex irritation, such as dentition, indigestible 
food, or sudden atmospheric changes, or to rachitis, or to the presence 
of postnasal adenoids, the treatment is both prophylactic and curative. 
Prophylaxis consists in the avoidance of cold ; the use of a simple diet, 
particularly at the evening meal; the rendering of the air of the 
bedroom moist by means of steam, or at least by the avoidance of 
dust-laden, furnace-heated air, and by the removal of dental irritation 
and nasal hypertrophies, which make the child a "mouth-breather." 
Iron and arsenic are useful tonics if the child is anaemic and rachitic. 
Much relief can be provided such patients by having them sleep in a 
"bronchitis tent." (See article on Bronchitis.) Small doses of the 
bromides, chloral, belladonna, or opium may be resorted to at bed- 
time. A very useful prescription for this purpose is that which 
follows : 

I$— Sodii bromidi 5j (4.0). 

Syrupi lactucarii . fgij (60.0).— M 

S. — Teaspoonful to a dessertspoonful (4.0-8.0) on going to bed, and once or 
twice during the night if needed. 

When the attack is present, a cold cloth should be wrapped about 
the neck and the child placed at once in a hot bath, the air of the 



CYSTITIS. 727 

room being moistened by the steam escaping from a kettle of boiling 
water or by pouring water upon unslaked lime. If the paroxysm is 
very severe, a few whiffs of amyl nitrite may be employed. It is also 
useful to disseminate the fumes of menthol through the air of the room 
by heating some crystals in an iron spoon. If the fumes are strong 
enough to produce a distinct odor, they are present in sufficient 
amount. 

CYSTITIS (ACUTE). 

If, by reason of exposure to cold, injury, the introduction of foreign 
bodies, such as dirty catheters, or the presence of gonorrhoea or other 
disease due to an infection, an acute inflammation of the bladder 
ensues, it is accompanied by a sensation of weight and vesical fulness, 
by pain, tenesmus, and inability to retain the urine. Sometimes the 
last-named condition may be reversed and retention of urine be 
present. 

If the general system responds to the local inflammation, as evidenced 
by increased arterial excitement and fever, aconite, in full doses of the 
tincture, should be used, and it should be combined with small amounts 
of sweet spirit of nitre and citrate of potassium, as follows: 

1$ — Tincturae aconiti f 5iij (12.0). 

Spiritus aetheris nitrosi f§j (30.0). 

Liquoris potassii citratis . q s. ad fovj (180.0). — M. 

S. — Dessertspoonful (8.0) every four hours until all fever ceases and the pulse 
is quiet 

At the same time a hot compress should be applied over the bladder, 
but it should not contain turpentine or any irritant substance which 
may be absorbed from the skin and when eliminated by the kidneys 
irritate the bladder-walls. Leeches may be placed upon the perineum 
or cups applied to the region of the sacrum. In some cases belladonna 
may be used with or without aconite in the dose of 5 to 10 minims 
(0.30-0.60) of the tincture three times a day, and it is worthy of note 
that this drug is particularly serviceable in cystitis due to cold. If the 
urine is acid and irritating, 5 minims of potassium hydroxide every four 
hours, or the citrate or acetate of potassium, may" be used, if there 
is much pain and bearing-down, an enema of 30 minims (2.0) of 
tincture of deodorized opium in 2 ounces (60.0) of starch-water may be 
employed, or the opium may be given in suppository. 

Sometimes a belladonna suppository is of more service, and an 
iodoform suppository will often relieve the pain by its local anaesthetic 
effects. Hot enemata, without any drugs, are often valuable as a 
means of relief, and a hot sitz-bath is very efficacious. Cannabis 
indica, if an active preparation can be had, may be better than opium 
in some cases to relieve the pain, since it seems to affect the bladder 
favorably. The other curative measures are hygienic, and consist 
in maintenance of the recumbent posture, absolute physical and 



728 DISEASES. 

mental rest, avoidance of all foods which are stimulating, as rare 
meats and highly seasoned dishes, and abstinence from all varieties 
of alcoholic beverages. 

Should the inflammation be severe enough to become purulent, the 
physician should order phenyl salicylate in the dose of 10 grains (0.60) 
three times a day. This drug, being broken up in the bowel into 
phenol and salicylic acid, is so eliminated that it renders the urine 
antiseptic; or in other instances, if the urine is alkaline and phos- 
phatic, hexamethylenamine (urotropin or uritone) in the dose of 5 to 10 
grains (0.30-0.60) should be given in capsule after food or drink three 
or four times a day. 

Laxatives are to be employed with persistence if the bowels are 
confined, and saline purgatives in the early stages are generally better 
than vegetable purges. 

Quinine should not be used against the fever, as it is contraindicated, 
owing to its irritant effects upon the bladder. 



CYSTITIS (CHRONIC). 

Given a case of chronic cystitis it must be borne in mind that a 
pathogenic microorganism is usually the cause, or at least is responsible 
for the continuance of the condition. The urine should be examined 
bacteriologically and if a specific organism is found in pure culture, 
or even in dominant numbers, an autogenous vaccine should be given, 
or, if this is not possible, a stock vaccine should be used. (See Vac- 
cines.) If the colon bacillus is present the urine should be rendered 
acid by the use of acid sodium phosphate (which see) and hexamethyl- 
enamine given freely. In other infections alkaline diuretics are usually 
better. Obstinate cases which do not yield to treatment should be 
examined by means of the cystoscope and treated locally, as when the 
trouble is due to a tuberculous ulcer or to a growth. The prostate 
should also be examined to determine if it interferes with proper empty- 
ing of the bladder and urethral stricture is to be sought for. 

The drug treatment of chronic cystitis consists in the use of remedies 
which will stimulate the diseased mucous membrane, cause a normal 
secretion of mucus, and so influence the urine that the mucus already 
formed will be passed out and the fluid rendered alkaline or acid, as 
may be desired. When the secretion of mucus in large amount is 
persistent, the urine should be rendered alkaline by the use of potas- 
sium hydroxide or the citrate of potassium. The bitartrate of potas- 
sium, unlike the other vegetable salts of potassium, such as the acetate 
or bicarbonate, is eliminated as the bitartrate of potassium, and, as it 
is acid, cannot be employed. 

We acidify the urine when it is necessary to dissolve the phosphates 
and to prevent deposits in the bladder. The three best drugs for this 
purpose are hexamethylenamine (urotropin or uritone) in the dose of 



CYSTITIS. 729 

5 grains (0.3) three or four times a day, acid sodium phosphate in the 
dose of 20 to 40 grains (1.3-2.6), or benzoate of ammonium 10 to 20 
grains (0.60-1.3) three times a day. The rule may be laid down that 
if the urine is high-colored and is strongly acid, alkalies are useful; 
whereas if it is light in color, but loaded with phosphates, urotropin 
or uritone should be employed. Hexamethylenamine (urotropin or 
uritone) may be given to prevent decomposition of the bladder 
contents, and if so acid sodium phosphate should also be used. 

The remaining remedies which are employed internally in chronic 
cystitis are those which are directed to the improvement of the mucous 
membrane of the bladder, and consists of buchu in the form of the 
fluidextract in the dose of \ to 1 drachm (2.0-4.0), well diluted; arbutin 
or ursin, 3 to 5 grains (0.20-0.30); or the fluidextract of uva ursi, 
dose 30 minims to 1 drachm (2.0-4.0). All of these are better fitted 
for the treatment of subacute than chronic cystitis, as they are not 
sufficiently active for the chronic forms. 

In cystitis of a very chronic type, with great vesical atony, strychnine 
is of service, and drop-doses of tincture of cantharides do great good. 
Turpentine may also be used with advantage in 5- to 20-minim (0.3- 
1.3) doses, as may also the oils of eucalyptus, sandal-wood, cubebs, 
and copaiba. 

One of the best measures for the relief of chronic cystitis is to irrigate 
the bladder daily with warm normal saline or water containing 
bichloride of mercury in the proportion of 1:10,000, as this washes 
away pus and mucus, and prevents irritation. Solutions of nitrate of 
silver have been used with great success where the urine is muco- 
purulent, and Thompson recommends the use of a solution of the 
strength of 1 grain to 4 ounces (0.06-120.0) of water, gradually 
increased to 2 grains to the ounce (0.12:30.0). Others, such as Gard- 
ner, Richardson, and Potter, recommend the use of stronger solutions, 
5 grains to the ounce (0.30:30.0) of water, claiming that while these 
amounts may produce serious effects in some instances, they are very 
efficacious in obstinate cases. The physician should have at hand a 
solution of common salt, which he should inject into the bladder at 
once if the effect of the silver solution is too painful or seems excessive. 
This treatment is suited only to the most chronic cases. 

A weak solution of mercurol and a saturated solution of chloretone 
may also be used with advantage. 

All these measures are suitable for the treatment of cystitis in the 
male and female, but it is to be noted that injections into the female 
bladder are made much more readily than into that of the male, because 
of the shortness of the female urethra. In either case the operation 
is best performed by attaching a small funnel to a soft-rubber catheter 
and filling the bladder by raising the funnel when full of water above 
the patient's belly. 



730 DISEASES. 

DIABETES INSIPIDUS. 

Diabetes insipidus is a profuse urinary flow dependent upon some 
disorder of the innervation of the kidney or upon disease of the pituitary 
body. Its treatment consists in the use of astringents and tonics, and 
in some cases in the employment of opium or belladonna, particularly 
if the oversecretion is due to nervous irritability. Gallic acid may be 
used in 20-grain (1.3) powders three times a day, and the fluidextract 
or wine of ergot is often of service given in the dose of 30 minims to a 
drachm (2.0 : 4.0) of the former or a wineglassful (30.0) of the latter. 
As tonics the sulphate of iron and strychnine are indicated. Pituitary 
gland may be employed with advantage in some cases. 

DIABETES MELLITUS. 

In the treatment of this affection it should be remembered that it 
is not a disease in itself, but a symptom of several morbid processes. 
For this reason a remedy which succeeds in one case may fail in another. 

The treatment of diabetes mellitus is both dietetic and medicinal, 
of which the more important part is the diet, since diabetes is a state 
of the body in which the system is unable to utilize properly the carbo- 
hydrate portions of the food, and as a result sugar is passed out in 
the urine. Glycosuria, or the mere presence of glucose in the urine, 
is not diabetes, although if it is constant it may be the early stage of 
the disease. Manifestly, both of these states are to be treated by 
decreasing the intake of those articles which will produce glucose 
namely, the starches, and therefore the carbohydrates are to be greatly 
cut down in all antidiabetic diet-lists; but changes in the diet should be 
very gradually instituted, since sudden cutting off of starches may cause 
marked nutritional disturbance and precipitate an attack of diabetic 
coma. In these patients the sudden deprivation of carbohydrate foods 
results in production of carbohydrate substances from the body proteids 
and fats, and it is essential to administer foods containing starch to 
protect the tissues of the patient and to prevent the production of 
poisons which are produced by this tissue breakdown. This is a most 
important point to be remembered. 

Given a case of diabetes the physician should obtain a record of the 
case by studying it for several days before he institutes dietetic treat- 
ment. After he has determined the amount of urine passed daily, 
the sugar output, and the presence or absence of diacetic acid or ace- 
tone, he may proceed to cut down the starch intake gradually. If 
three or four days after this the urine becomes entirely free from sugar, 
the patient may be given approximately 100 Gm. (3 ounces) of bread 
in twenty-four hours. If no sugar appears in the urine 200 Gm. 
(6 ounces) of bread are given the next day, and if within the next 
twenty-four hours sugar appears it would seem evident that the 



DIABETES MELLITUS. 731 

patient can deal with 100 Gm. but not with 200, and 100 should be 
allowed him not only to please his palate but to protect him from 
tissue breakdown and diabetic coma. If the complete withdrawal 
of starch does not check the sugar excretion, small portions of starch 
should be given for the reason just given. The danger does not lie 
in the escape of sugar in the urine, but in upsetting metabolism. 
Fats, to some extent, take the place of starches. Butter, if freely 
used, should first be carefully washed with water, containing a little 
soda, to free it from bodies such as butyric acid, which can be readily 
converted into acetone-like bodies. We must prescribe fat meats, 
and, contrary to old teaching, order rich milk instead of skimmed 
milk. 

Diabetics can often utilize a single carbohydrate in fairly large 
amounts without glycosuria when they are unable to take several 
starches. The most easily dealt with starches for them have been 
found to be oatmeal and potato. Tests must be made until the amount 
of these carbohydrate substances that can be taken daily, without 
increasing glycosuria, are determined. Often a "starvation day," 
when no starch is taken, will enable the patient to deal with larger 
amounts of starch afterward. 

The following articles are allowed: 1 Meats of all kinds (except 
liver), eggs, fish, cheese, butter, and cream; oyster-plant, asparagus (?), 
tomatoes, almonds, pecan nuts, butternuts, walnuts, and cocoanuts; 
string-beans, beet tops, radishes, mushrooms, lettuce and water-cress, 
cauliflower, spinach, and onions. Celery and cucumbers may also be 
permitted. 

Of the foods and drinks to be avoided, we have all forms of sugar, 
all forms of starch, such as ordinary flour, cornmeal, arrowroot, sago, 
tapioca, barley, carrots, beets, parsnips, pie-plant, peas and beans, 
chestnuts, and most of the fresh fruits, cider, beers, champagne, sweet 
wines, and honey. (See Levulose.) 

The patient should have a diet so arranged as to give all the calories 
he needs without starch, and this may be accomplished if he takes daily 
2 ounces (60 Gm.) of butter, 2 eggs, 2J drachms (10 Gm.) of olive 
oil, 1 ounce (30.0) of fat cheese, 1 quart (960 mils.) of milk, and 1 
ounce (30.0) of alcohol. This will give the man 1600 calories, and he 
needs but approximately 2400 to 3000, which can be obtained by 
additional food. (See Diastase.) 

Comparatively recently two heroic methods of treating diabetes 
mellitus have been brought forward. If they are to be instituted I 
believe the physician should have preliminary tests as to the patient's 
state, as already pointed out, but their advocates do not insist on 
this. Guelpa's method consists in absolute starvation with free 
purgation by means of a saline laxative for two or three days, after 

1 It is worthy of note that certain persons having a slight glycosuria without serious 
injury, waste under a limited diet, and require ordinary fare to support the body plus 
the sugar drain. 



732 DISEASES. 

which time the patient is often sugar-free. After this the patient is 
gradually put back on a vegetable and starch diet, but the amount of 
protein allowed is very limited. 

The so-called Allen method is as follows: For forty-eight hours after 
admission to the hospital the patient is kept on an ordinary diet to 
determine the severity of his diabetes. I think that this is too short 
a period, since my experience has shown that this determination can 
only be approximately made by a study covering from five days to a 
week. At the end of two days the patient is put to bed and no food 
allowed save whiskey and black coffee, the whiskey being given in the 
coffee, 1 ounce of whiskey every two hours from 7 a.m. to 7 p.m. — in 
other words, 6 to 8 ounces a day. Sodium bicarbonate is sometimes 
given in the dose of 2 drachms every three hours, if there is much 
evidence of acidosis, as indicated by strong acetone and diacetic 
reactions in the urine, or a strong acetone odor to the breath. It is 
stated, however, that in most cases this is not necessary and that there 
is no danger of producing coma by starvation. If this is true it 
controverts the belief heretofore universally held by medical men, and, 
until further evidence is adduced, I prefer to remain on the side of 
caution by regarding suddenly induced starvation as dangerous. This 
is particularly true if the patient has suffered from the malady for a 
long time and of those who have an acetone breath or an exceedingly 
rapid form of the disease. 

The patient is kept in bed and starved until the urine is sugar-free. 
It is stated that the disappearance of sugar is rapid. If there has been 
5 or 6 per cent., after the first starvation day it goes down to 2 per cent., 
and on the third day the patient is sugar-free, or certainly by the end 
of the fourth day this occurs. It is claimed that there may be a slight 
loss of weight amounting, perhaps, to 3 or 4 pounds, and Allen goes so 
far as to say that a moderate loss of weight in most diabetics is to be 
desired. Here, again, I think that this statement is too dogmatic. 
It may be true of obese patients, but it certainly is not true of the 
emaciated ones, particularly if the patients are young. The question 
also arises as to how many patients are able to take nothing but whiskey 
with black coffee to the extent of 6 to 8 ounces a day with advantage. 
I have yet to find one. It may be true that the sedative effect of this 
amount of alcohol overcomes the nervous effect of large quantities of 
black coffee, but many diabetics suffer very intense nervous irritability, 
which is often emphasized by distressing pruritus, and I question 
whether this so-called diet would be tolerated, even if the stomach 
and the liver were able to deal with this amount of alcohol without 
distress. Certainly, there are a very large number of persons who can- 
not take this amount of whiskey, even if it is diluted with a consider- 
able quantity of food or drink, without inducing gastric and hepatic 
symptoms. 

When the patient is sugar-free he is allowed to get up and is placed 
upon vegetables containing approximately 5 per cent, of carbohydrate. 



DIABETES MELLITUS. 733 

These vegetables are thrice boiled with changes of water, so that their 
actual carbohydrate content is reduced probably one-half. A moder- 
ate amount of butter-fat is permitted. If the patient eats very 
heartily of green vegetables, even if they are thrice boiled, he may 
obtain more carbohydrate than his system can utilize. The typical 
dietary for the first day of feeding is as follows : 

Breakfast. 

String beans, 4 heaping tablespoonfuls. 
Asparagus, 4 heaping tablespoonfuls. 
Tea or coffee. 

Dinner 

Carrots, cooked, 2 heaping tablespoonfuls. 
Spinach, cooked, 3 heaping tablespoonfuls. 
Tea or coffee 

Supper. 

Cucumbers, 12 slices. 
Celery, 6 pieces 6 inches long. 
Tea or coffee. 

In diet list No. 2 cabbage and onions are substituted for some of 
the vegetables already named, and on the third and fourth days the 
variety of green vegetables is increased as to number and cream and 
butter added. The diet, day be day, becomes somewhat more gen- 
erous, so that diet list No. 12 contains: 



Br 



EAKFAST. 



Bacon, 2 slices 6 inches long. 
1 egg. 

Spinach, 2 heaping tablespoonfuls. 
Coffee, butter, and cream. 

Dinner. 

Steak, one, very small. 

Salt pork, 4 slices. 

Cabbage, 3 heaping tablespoonfuls. 

Onions, 3 heaping tablespoonfuls. 

Butter, cream, and tea. 

Supper. 

1^ ounces of beef balls. 

Celery salad, 2 tablespoonfuls; olive oil. 

Tomatoes, 2| tablespoonfuls. 

In addition the patient is allowed during the day 2 ounces of butter 
and 10 tablespoonfuls of 40 per cent, cream. If, however, oxybutyric 
acid, or diacetic acid, is present in the urine in any amount, and par- 
ticularly if any evidence of diabetic stupor is seen, it is to be recalled 
that as these substances are largely derived from the breaking down 
of fats they must be used with care if at all. If, as the diet is grad- 



734 



DISEASES. 



ually increased, sugar appears, the diet is again cut down, and it is 
important to remember that the increase in the proteid elements of 
diet may increase the elimination of sugar. 

Joslin, in his excellent book on "Diabetes" gives the following table 
which shows the carbohydrate content of various vegetables suitable 
for diabetics. 

DIET. 

Strict Diet. — Meat, Fish, Broths, Gelatine, Eggs, Butter, Olive Oil, Coffee, 
Tea and Cracked Cocoa. 



Foods Arranged Approximately According to Percentage of 




Carbohydrates. 






Vegetables 








(Fresh or canned) 










5 per cent. 1 


10 per cent. 1 


15 per cent. 


30 per cent. 


Lettuce 


Tomatoes 


Onions 


Green peas 


Potatoes 


Cucumbers 


Brussels 


Squash 


Artichokes 


Shell beans 


Spinach 


sprouts 


Turnips 


Parsnips 


Baked beans 


Asparagus 


Water cress 


Carrots 


Canned lima 


Green corn 


Rhubarb 


Sea kale 


Mushrooms 


beans 


Boiled rice 


Endive 


Okra 


Beets 




Boiled 


Marrow 


Cauliflower 


Kohl-rabi 




macaroni 


Sorrel 


Egg plant 


Pumpkin 






Sauerkraut 


Cabbage 








Beet greens 


Radishes 








Dandelion 


Leeks 








Swiss chard 


String beans 








Celery 


Broccoli 










Fruits 








Ripe olives 


contain 20 per cent. 


Lemons 


Apples 


Plums 


fat 




Oranges 


Pears 


Bananas 


Grapefruit 




Cranberries 

Strawberries 

Blackberries 

Gooseberries 

Peaches 

Pineapple 

Watermelon 


Apricots 

Blueberries 

Cherries 

Currants 

Raspberries 

Huckleberries 


Prunes 



See p. 640 for nutritional balance and proportions of foodstuffs in normal 
persons. 

I think that the average physician will find some difficulty in 
making his patients adhere to the rigid rules described above, but, for 
that matter, he usually finds it difficult to make his diabetic patients 
adhere to any rules. That Dr. Allen and his followers have been 
able to produce excellent results by this method is undeniable. That 
it can be applied in the sweeping manner which its description indi- 
cates, I very much doubt. This plan of treatment savors too much 
of rigid routine applied in a disease which of all others lends itself but 
poorly to any absolute hard-and-fast plan. 

Joslin and others have found it advantageous in cases of long stand- 
ing and severity, without otherwise changing the habits or diet, to 

1 Reckon available carbohydrates in vegetables of 5 per cent, group as 3 per cent., of 
10 per cent, group as 6 per cent. 



DIABETES MELLITUS. 735 

begin treatment by omitting fats in order to decrease the source of 
acid bodies, after two days to cut out proteins, and simultaneously to 
cut the amount of carbohydrates to 10 grammes, and then if the 
urine is not sugar-free to starve the patient as above described. 

The wide divergence of methods of diet in diabetes shows how little 
we still know of the pathology of this disease. (See Foods for Sick.) 

A useful artificial milk will be found described in Part III. 

The treatment of diabetes by drugs is varied by the condition of 
the patient, the cause of his disease, and the quantity of sugar in the 
urine. While the drugs most commonly employed are used in many 
instances without any knowledge of how they act, and have each of 
them warm supporters among authorities, much of the treatment 
must depend upon whether or not a rheumatic or gouty taint is the 
cause of the trouble, or whether it is due to high living and little exercise, 
producing a plethoric, congested, overloaded system. In the first 
class of cases iodide of potassium and the salicylates will be most 
serviceable; in the second class, a restricted diet, moderate exercise, 
and purgation to relieve engorgement of the hepatic and gastric 
veins may be needed. In the cases of gouty diabetes, where relief 
does not follow the use of the iodides and colchicum, resort must be 
had to arsenic and lithium citrate or carbonate, a combination pecu- 
liarly adapted to such a condition according to several authorities. 
Indeed, arsenic is a sheet-anchor with many practitioners in all forms 
of diabetes, and should be given in fairly large, constantly repeated 
doses for a long time. A very much larger body of medical men rely 
on opium or one of its alkaloids, such as morphine or codeine. The 
former is used in the dose of \ to \ grain (0.015-0.3) three times a 
day; the latter, 1 to 5 grains (0.06-0.30) three times a day, and the 
writer has found them very useful. The morphine is by far the more 
powerful for good, but some patients who are diabetic must take 
large ascending doses of opiates to get good results. (See article 
on Opium.) In cases depending upon a gouty diathesis the use of 
salicylic acid is often of value, the dose being 10 to 15 grains (0.60- 
1.0) three times a day. 

In those cases of diabetes in which diet will control the disease the best 
clinicians insist that drugs should be avoided, for when opium or any 
of its alkaloids are used it is eventually necessary to give increasing 
doses, which finally become enormous, as much as 7 grains (0.45) of 
morphine a day being taken by some persons. Once having begun 
the use of opiates in severe cases, it is very dangerous to stop them, 
for clinical experience has shown that many of these patients waste 
rapidly and generally break down when this is done. In regard to 
the time of day at which to give the morphine or codeine, they are gen- 
erally given about one hour after meals. Under these circumstances 
the drugs seem to decrease diuresis more than if the dose precedes the 
meal; further than this, the stomach is not disordered. In some 
cases results will be obtained from opium when its individual alka- 



736 . DISEASES. 

loids fail. ^ Careful observation of the patient should be carried out 
to determine the proper beginning and subsequent doses, and if at 
first the opiates fail to give relief discouragement should not be felt. 

Unfortunately, we have no positive knowledge as to the causes 
of diabetes, and in consequence cannot explain the manner in which 
opium, codeine, or other drugs produce relief. 

The excessive thirst of diabetes can be best allayed by the use 
of alkaline waters containing non-purgative salts. It is useless to 
cut off the water-supply, to the production of great suffering, but 
the patient should use moderation in drinking so far as possible, 
because the overloading of the stomach tends to disturb digestion. 

The wasting coining on in diabetes is to be treated by careful diet, 
rest, and the supply of all the food which the patient can digest. In 
many instances the amount of aliment ingested is extraordinarily large, 
while in others digestion is so impaired that food cannot be freely taken. 

If cachexia comes on, iron, strychnine, bitter tonics, and the lacto- 
phosphates of lime and sodium are to be used to support the circulatory 
and nervous systems. Tea and coffee and all forms of food needing 
sweetening may be rendered palatable by the use of saccharin or of 
glycerin. The former passes through the body unchanged; the latter 
increases the glycogen in the liver, but checks the formation of sugar. 

Diabetic coma is a most dangerous complication of this disease, and 
should be treated as actively as our knowledge of its cause permits. 
It is thought by some that the symptoms are entirely dependent upon 
the presence in the blood of /3-oxybutyric acid, and that hypodermoclysis 
or the intravenous injection of normal saline solution (7 : 1000) should 
be resorted to. Stadelman insists upon the employment intravenously 
of 150 mils, of normal salt solution to which 7.2 Gm. of sodium carbonate 
and 4.6 Gm. of sodium bicarbonate have been added. The injection 
is continued until the urine is alkaline. Unfortunately, the statistics 
of this method of treatment are not good so far as permanent recovery 
is concerned, but some form of transfusion should be used.. (See 
Transfusion.) As the condition is a typical toxaemia, a full dose of 
sulphate of magnesium or sulphate of sodium should be given, to aid 
elimination by the bowels if they are loaded with feces. Otherwise 
purgatives should not be used, as they possibly concentrate the 
poisons in the blood. Hypodermic injections of ether should be 
resorted to to support the heart. If hypodermoclysis is resorted to 
carbonate of sodium must not be used as it will cause sloughing, and 
if sodium bicarbonate solution is so employed it must not be boiled, as 
boiling changes it into the carbonate. 

In severe cases of 'diabetes in which coma is feared because of a 
sudden increase of acetone in the urine or in which mild premonitory 
drowsiness is present, bicarbonate of sodium should be given in full 
doses, as much as \ to 1 ounce (16.0-30.0) a day, and a full carbo- 
hydrate diet be instituted, boiled rice being one of the best starches 
to employ. Levulose or dextrose in solution may be given freely by 



DIARRHCEA AND DYSENTERY. 737 

the mouth, by the rectum, and even intravenously; as much as J to 
1 gramme to the kilo of body weight. When given by the rectum the 
proportions are 15 Gm. to 1000 of water at the rate of 30 or 40 drops to 
the minute. (For method, see Peritonitis, Part IV.) When given 
intravenously it is best dissolved in normal salt solution in the strength 
of 5 per cent. When given by the rectum salt solution should not be 
employed, and the direct enema or drop method may be used. 

DIARRHCEA AND DYSENTERY. 1 

The term diarrhoea is applied, perfectly correctly, to all forms 
of intestinal disturbance accompanied by the passage of liquid stools, 
and its meaning, "to run through," expresses the state it represents. 
The treatment of each form of diarrhoea depends upon its cause, 
and no case can be intelligently treated in which the physician fails 
to recognize this aspect of the case. Diarrhoea is but a symptom, 
not a disease, and must be regarded solely as an evidence of intestinal 
disorder. 

While the same drugs are prescribed in many forms of the trouble, 
we may divide the cases of diarrhoea into four classes, as follows: (a) 
Those in which the laxity is due to a catarrh, acute or chronic, of the 
intestinal mucous membrane, causing the passages to contain mucus; 
(6) those in which, owing to disordered innervation, a profuse out- 
pouring of liquid takes place from the bloodvessels into the intestinal 
lumen; (c) those in which, owing to disease, the glands fail to prepare 
juices to digest the food properly; and finally (d) those cases in which 
ulceration causes irritation and bloody purging. 

The treatment of the catarrhal form first named consists primarily 
in regulation of the diet, which should be made up chiefly of milk, 
boiled or predigested, or of milk whey, and in the administration of 
castor oil or other mild purge, such as sulphate of magnesium, to 
sweep out fermenting food and mucus. Enough laudanum should 
accompany this oil to prevent griping, and it is well to add bicarbonate 
of sodium, grains 20 to 30 (1.3-2.0) to the dose, both to aid the action 
of the oil and to render the bowel alkaline in reaction (normal) instead 
of acid, as caused by the fermentation abnormally present. A mustard 
plaster or other counterirritant should be applied to the abdomen. 
Often in the milder forms of mucous diarrhoea this is all that is needed, 
but more frequently it must be followed by the use of tonics and 
astringents, such as nitrate of silver and hyoscyamus, in the following 
pill: 

1$ — Argenti nitratis gr. ij (0.12). 

Extracti hyoscyami gr. v (0.3). — M. 

Fiant pilulse No. x. 

S. — One three times a day. 



1 The articles on Cholera, Cholera Morbus, and Cholera Infantum should be carefully 
read in connection with this article. 
47 



738 DISEASES. 

Or, 

1^— Plumbi acetatis gr. ij (0.12). 

Extracti opii gr. ij (0.12) — M. 

Fiant pilulae No. x. 

S. — One three times a day. 

If these stop the diarrhoea, yet there still seems to be a tendency for 
it to return or atony is present, we should use a pill containing the 
extract of chiretta or employ nitromuriatic acid, or, better still, dilute 
nitric acid and compound tincture of cardamoms, because the constant 
tendency to relapse indicates a deficient secretive action on the part 
of the intestinal glands, which these remedies are prone to improve: 

tf— Acidi nitrici diluti f 5j (4.0). 

Tincturae cardamomi compositae . . . f§ij(60 0) 

Tincturae gentianae compositae .... f§ij (60.0). — M 
S. — Dessertspoonful (8.0) every four hours. 

In the second form of diarrhoea named — that in which serous cr 
watery purging is present — the treatment is radically different. In 
these cases the bloodvessels of the gut are relaxed and leaking, and 
must be contracted and made water-tight. This dilatation may result 
from fear ("nervous diarrhoea"), from exposure to cold, or from 
exhaustion, extreme heat, and irritating food. If from irritating 
foods, they are generally swept out in the first flush of liquid. 

The measures to be adopted consist in those directed to the con- 
traction of the dilated and relaxed bloodvessels and the restoration 
of the proper nerve-supply to the parts. 

As the splanchnic nerves are the vasomotor nerves of the intestine 
as well as the inhibitory nerves of peristalsis, it is evident that drugs 
must be used which will cause stimulation of these fibres, and the 
chief of these is found to be opium, which diminishes intestinal peris- 
talsis and secretion by just such an influence. In the same way 
small doses of volatile oils are of service, and camphor and spirit of 
chloroform may be used. As there is relaxation, astringents are indi- 
cated; and as sulphuric acid is not only astringent, but is eliminated 
by the lower bowel, it is peculiarly serviceable. We find, therefore, 
that the following prescription fulfills every indication: 

1$ — Acidi sulphurici aromatici f §ss (16.0). 

Olei cajuputi . . . . gtt. xl (2.60) 

Fluidextracti haematoxyli f 3 ij (8 0) 

Spiritus chloroformi f 3iv (16.0). 

Syrupi zingiberis . . . . q. s. ad f§iij (90.0). — M. 
S. — Teaspoonful (4.0) in water every two or three hours. 

If desired, kino or gambir may be used in lieu of the hsematoxylon, 
or the oil of cloves substituted for that of cajuput. Camphor or 
paregoric may also supplant these drugs: 

1$ — Acidi sulphurici aromatici f 5iss (6.0) 

Spiritus chloroformi f S ij (8.0). 

Tincturae opii camphoratae .... f5ij (60.0). 
Syrupi zingiberis . . . . q s. ad fgiv (120.0). — M. 
S. — Dessertspoonful (8 0) in water every two hours. 



DIARRHCEA AND DYSENTERY. 739 

Or, 

Ifc— Tincturse kino f 5 j i (30.0). 

Tincturse gambir compositse . . . . f oj (30.0). 

Misturae cretse f oiij (90 0). 

Aquae cinnamomi . . . . q. s. ad i'ovj (180.0). — M. 
S. — Shake well before using. Tablespoonful (16.0) every three hours. 

In some instances these attacks appear to depend upon hepatic 
disorder, and the only cure is to be obtained by the use of 2 to 6 
grains (0.12-0.40) of mercury with chalk (hydrargyrum cum creta) or 
calomel, given in J to \ grain (0.01-0.03) doses until 1 or 2 grains 
(0.06-0.12) have been taken. What is said of intestinal disorder from 
lack of secretion under the heading of Cholera Infantum applies very 
forcibly to these cases, and diarrhoea may persist for weeks, or only 
temporarily be held in check by the most powerful drugs, until the 
physician thoroughly flushes the intestine with bile by the use of 
calomel. 

For the purpose of establishing intestinal antisepsis, phenyl salicylate 
(salol) may be used, and naphthalene, thymol, or other drugs of this 
class may be employed, particularly salicylic acid. In other cases phe- 
nolsulphonate of zinc in the dose of from 1 to 4 grains (0.06-0.25) in 
powder or capsule is beneficial. Phenyl salicylate combined with chalk 
mixture may also be advantageously used. (See prescriptions under 
Salol.) Eudoxin, one of the new bismuth salts, is also of value. It 
is doubtful if true intestinal antisepsis can be produced by drugs ; and 
if they can, they probably destroy useful benign organisms as well as 
those which are malignant. 

Wood has highly recommended the use of 20 grains (1.3) of bismuth 
powder containing a minim or two of phenol. 

The regulation of the diet, which should consist in sterilized milk 
or koumyss, the former being predigested, is of the greatest impor- 
tance. 

The after-treatment consists in the use of tonics and a carefully 
regulated diet, which should be largely composed of milk and milk 
foods. 

The third class of cases consists chiefly of children who pass fetid, 
"mousy" smelling stools in summer darrhcea, with green, spinach-like 
masses, semi-digested food and which have distinct lientery. These cases 
may be due to deficient glandular action in any part of the alimentary 
canal, and are often cured by the use of pepsin and hydrochloric acid 
to aid the gastric processes. In other instances the duodenum is at 
fault, and should be stimulated by small doses of nitromuriatic acid, 
or by podophyllin in the dose of -fa to fa grain (0.0012-0.0015), with 
a little milk-sugar, or given in alcoholic solution. Similarly, ipecac 
in powdered form may be used in the dose of \ to \ grain (0.015-0.03) 
three times a day. In the case of children who are sufferers from rickets, 
lime-salts and common salt should be freely given. (See Cholera 
Infantum.) 

The fourth type, generally known as dysentery, is due in nearly 



740 DISEASES. 

all cases in the temperate zone to the micro-organism of Shiga, bacillary 
dysentery, and to the drinking of impure water, exposure to heat or 
cold, and the use of improper food. It is in most cases a very obstinate 
form of diarrhoea, requiring much skill and patience for its cure. 
Usually it is a good plan to start treatment with \ ounce (15.0) of castor 
oil to sweep out the bowel. (See Antidysenteric Serum, Part III.) 
Absolute rest in bed, heat or counter-irritation over the belly and a 
diet of whey or thin boiled rice is to be ordered. Milk, if curds appear 
in the stools, is forbidden. There are three remedies which are far 
above all others in value. The first of these is sulphate of magnesium; 
the second, sulphuric acid; the third, calomel. 

The magnesium salt should be used in a special manner to be effec- 
tive. (See Magnesium Sulphate.) If calomel is used, it must be 
given in full purgative amounts, but is contraindicated if much weak- 
ness is present. 

In amoebic dysentery there can be no question that emetine is the 
nearest approach to a specific that we possess, both as a cure and to 
prevent complications. (See Ipecacuanha, Part II.) In bacillary 
dysentery ipecac is useless and Flexner's polyvalent vaccine or Shiga's 
serum may be tried. (See Antidysenteric Serum.) 

The important points to be remembered, aside from the use of 
emetine in amoebic dysentery, are that there is often an associated 
bacterial infection and that the amoeba deeply buried in the floor 
of the ulcers cannot be reached by colonic injections. The best treat- 
ment would seem to be: (1) The intramuscular dose of emetine 
hydrochloride in the dose of J to § grain (0.03-0.04) once or twice a 
day; and (2) the control of excessive purging by full doses of bismuth 
subcarbonate. If purging is not very excessive the use of magnesium 
sulphate and aromatic sulphuric acid (see Magnesium Sulphate) may 
be resorted to as in bacillary dysentery. Large rectal injections of a 
solution of quinine in the proportion of 1:3000 may be used, as this 
drug destroys the amoebae. (See Ipecacuanha, Part II, and Entero- 
clysis, Part III.) As Vedder has shown that nitrate of silver in so 
weak a solution as 1:300,000 kills the Amoeba dysenteries, it can be 
employed for irrigation purposes with advantage, associated with 
emetine hypodermically. In obstinate chronic cases, even if they 
are very feeble, the best treatment is appendicostomy with irrigation 
of the colon through the opening. 

If the passages are slimy and bloody, -$%-$ grain (0.0003) of bichloride 
of mercury every hour or two is of service, and if much blood is present 
high rectal injections of hamamelis water and water, half and half, are 
of value. The following mixture may be gently introduced into the 
bowl in feeble cases: 

I$— Sodii boratis 5.1 (4.0). 

Tincturse benzoini ........ 3j (4.0). 

Spiritus camphors . fgj (30.0). 

Aquae ferventis Oij (960) mils.). — M. 



DIARRHCEA. 741 

Recently the injection of water or medicaments into the bowel for 
the purpose of influencing the intestinal wall has given way to irri- 
gation by means of an inlet and an outlet tube. The inlet tube should 
be attached to a fountain syringe, and the outlet tube be long enough 
to reach to a vessel by the side of the bed, and of sufficient calibre to 
carry off flaky mucus. In many cases of dysentery of a mild form 
rectal irrigation will suffice, but if the entire colon is involved higher 
injections are necessary and the use of an outlet tube is not feasible. 
The irrigation should be continued until the returning fluid becomes 
perfectly clear and free from foreign particles. Probably the best 
solution to employ for irrigation where much mucus and pus is present 
is one of bichloride of mercury, 1 : 5000. When this is used, a pure 
water injection or one of 1 : 30,000 should follow it, in order to prevent 
absorption of too much mercury into the system. If for any reason 
the effect of the bichloride is feared, boric acid may be used in the 
proportion of 1 drachm (4.0) to the pint (480 mils.), or 15 grains (1.0) 
of phenolsulphonate of zinc added to 1 quart (960 mils.) of hot water 
be injected. 

If the ulcers are very old and chronic, nitrate-of-silver injections, 
of the strength of 10 to 20 grains (0.6-1.3) to the pint (480 mils.) of 
water, may be employed in large bulk, a. salt solution being at hand 
for the altering of the silver salt if the local action which ensues is too 
severe. 

DIARRHCEA (CHRONIC). 1 

This is one of the most obstinate conditions which the physician 
is called upon to treat. It may be due to nervous irritability of the 
bowels, so that the entrance of food or drink sets up an excessive 
peristalsis which so hurries the food and drink through the alimentary 
canal that digestion and absorption are imperfectly performed. Chronic 
diarrhcea may also be due to chronic intestinal catarrh, to ulcerations 
of the small or large intestine, as after typhoid fever, or to rectal dis- 
ease, which reflexly causes hyperperistalsis. Fissure of the anus often 
causes persistent diarrhcea by reflex irritation. In those cases due to 
hyperperistalsis an advantage is often gained by directing the patient 
to take as little liquid as possible, particularly at meals, and to avoid 
coffee or other stimulants to reflex activity. Highly seasoned foods 
are also to be avoided. Meats should be preferred to vegetables, and 
an absolute diet of peptonized milk may be ordered, the milk being 
given in tablespoonfuls every few minutes, rather than in large amounts. 
The patient should remain in bed. Counterirritation, constant and as 
severe as the patient can stand, should be used over the abdomen. 
Suppositories and rectal injections seldom benefit this class of cases, 
but a pill composed as follows may be useful : 

1 Read with this article those on Diarrhoea and Dysentery and Enteroclysis. 



742 DISEASES. 

1$ — Argenti nitratis gr. iv (0.25). 

Extracti hvoscyami gr. x vel xxx (0.60-2.0). 

Extracti opii gr.ij vel iv (0.1 2-0.25) .— M. 

Fiant pilulae No. xx. 

S. — One pill one hour before each meal. 

This pill should be coated with phenyl salicylate so that it will pass 
through the stomach before dissolving. 

In other instances some of the astringent prescriptions given under 
the article on Diarrhoea are better than the above. 

If the catarrhal state is persistent, no remedy compares to the chloride 
of ammonium, dose 5 grains (0.3) every four hours in fluidextract of 
liquorice and water. Where the catarrhal state is exceedingly chronic 
and obstinate it is well to employ 3- to 5-grain (0.20-0.3) doses of 
potassium iodide. In many cases where the condition of mucous 
diarrhoea becomes chronic it is necessary to resort to enteroclysis (Part 
III.) and the treatment needed in cases of chronic intestinal catarrh. 
(See Diarrhoea, Chronic.) 

In the cases due to ulcers of the rectum injections of nitrate of 
silver, 2 grains to the ounce (0.12:30.0), are of value, particularly if 
followed by a 5- or 10-grain iodoform suppository. Operative pro- 
cedure against anal fissure will often cure a diarrhoea due to this cause. 

In cases of so-called morning diarrhoea abstinence from liquids 
before going to bed the night before and a very dry and small break- 
fast are to be strongly recommended, with rest in bed during the 
morning hours. 

Dried sulphate of iron in pill is useful in cases of diarrhoea with 
anaemia. 

DIPHTHERIA AND MEMBRANOUS CROUP. 

Diphtheria is at first a distinctly local disease, the membrane in the 
upper air-passages forming a nidus from which the entire body ulti- 
mately becomes poisoned by the toxins of the micro-organism peculiar 
to the malady. While it is a fact that in some cases of membranous 
pharyngitis or laryngitis the true Klebs-Loeffler bacillus cannot be 
found, it is a fact that all cases should be treated as if they are true 
diphtheria, since in this way much good can be done, and no harm 
follows if the malady fails to develop. 

The best local application to the throat is peroxide of hydrogen. 
A cotton swab should be soaked with the undiluted 10- or 15-volume 
solution and pressed against the mucous membrane which is diseased ; 
or, if this cannot be done, a spray, from a glass atomizer, of the strength 
of 1 : 4 of water may be employed. The effect is often extraordinary. 
After a few applications the false membrane appears to exist only in 
disorganized shreds. If the nasal chambers become affected, a tepid 
solution of ordinary salt (7 : 1000) should be used in a spray or by means 
of a fountain syringe. The child is placed with its hips on the lap 
of one nurse and its head on the lap between the knees of another, 



DIPHTHERIA AND MEMBRANOUS CROUP. 743 

the dress of the nurse being protected by a rubber sheet, and the 
nasal cavities irrigated. The position of the child should be on its 
side, not on its back, and the face should be turned down sufficiently 
to allow the liquid, after entering the upper nostril, to flow out the 
lower one with ease, the child breathing through its mouth. The 
applications should be made as frequently as the membrane forms. 

A local application which has been much used is that of Loeffler. 
He directs that the mucous membrane shall be carefully wiped off by 
a pledget of cotton, and after this is done that a second pledget dipped 
in the following solution shall be pressed against the diseased area 
for ten seconds at three-hour intervals: menthol 2 J drachms (10 Gm.) 
dissolved in 9 drachms (36 mils.) of toluol, to which are added 1 drachm 
(4 mils.) of liquor ferri chloridi and absolute alcohol 2 ounces (60 mils.). 
This solution, if kept in a dark glass bottle, well stoppered, will keep 
for months. The author prefers to use peroxide of hydrogen in all 
cases, as it is efficacious and painless, whereas the application of 
Loeffler' s solution is apt to be very painful. 

The local use of iodine, phenol, and similar irritating and poisonous 
substances is not justifiable. 

Antitoxin Treatment. — This treatment excels all others in efficacy 
and usefulness, and should displace all other plans of treatment 
except the local applications. Of all the extraordinary advances 
made in pathology and therapeutics, the introduction and proof 
of the value of antitoxin in cases of diphtheria is perhaps most 
worthy of note. (For the study of Antitoxin itself, see Antitoxin, 
in Part III.) 

At the present time all manufacturers of antitoxin put up their 
product in hermetically sealed bulbs, or in special containers from 
which the serum may be directly injected without the use of an extra 
syringe. The advantage of this plan is that the physician is saved 
the trouble of sterilizing a syringe and can use a fresh piece of appa- 
ratus for each injection (Fig. 129). 

The great bulk of antidiphtheritic serum as compared to the small 
quantity of fluid used in ordinary hypodermic injections is a very great 
disadvantage, and many efforts have been made to concentrate the 
serum. The fact that the globulins of the serum either contain the 
antitoxin or at least are associated with it, has led to the separation 
of these globulins from the serum, and they have been found equally 
effective. Antidiphtheritic globulins are now on the market in two 
forms, the liquid and the dry. The liquid globulins hold 3000 units 
of antitoxin in about one-third the bulk of ordinary serum of equal 
strength. The dry globulin appears in small vials and is to be dis- 
solved in sterile water, the injection being given by the ordinary hypo- 
dermic syringe instead of using the combined container and injector 
used for serum or for liquid globulin. The small bulk of this dried 
product is a great advantage for physicians who are not near a base of 
supplies, as the tiny vials containing it can be readily carried in a pocket 



744 DISEASES. 

case for an indefinite time. Care that the water used is sterile is, of 
course, essential. It is claimed by many that the use of globulins is far 
less likely to be followed by erythematous rashes and joint pains than 
is the use of ordinary serum. Each vial of the dried globulin contains 
3000 units, but the vials of liquid globulin vary from 500 to 3000 units 
in their content. The strength is, of course, marked on each container. 
The dose of antitoxin serum is to be judged by its known strength 




The large end is securely closed by the rubber plunger itself, which is provided with a pro- 
tective flange ; jver this is fitted an aluminum-capped cork (shown above the finger-rests) with 
a central perforation through which the solid metal piston-rod passes— to be screwed into the 
threaded metal socket in the rubber plunger. The perforated cork, with its rigid metal cap, 
serves to hold the rod parallel to the glass barrel when under pressure, so there is no oblique 
action and no danger of breaking the glass. The needle end is closed by a rubber stopper which 
is paraffined in place, effectually excluding the air. The needle, with its flexible rubber con- 
nection, is placed in a tapered glass tube in such a manner that the point cannot come in con- 
tact with the glass and thus become blunted. The illustration shows the container after being 
emptied of its contents and with all attachments in place. The flexible needle connection fits 
snugly over the neck of the container and is held in position by a spearhead flange. When 
attachment is made it should be pressed up close to the shoulder. The finger-rests are of metal 
attached to a metal ring which slips over the glass bulb and rests against a flange of glass of 
double thickness ; they afford a sure grip, making this device almost equal to a regular syringe 
in safety and convenience of manipulation. 

or power of conferring immunity and by the severity of the disease and 
the susceptibility of the patient to the infection. Not less than 10,000 
units should be given as an initial dose and be repeated in from six 
to twelve hours. The dose should be repeated every six or twelve 
hours in severe cases, and doubled in amount in very malignant cases 
or in those with deeply seated cervical induration or laryngeal or 
nasal diphtheria. Large doses are required by young children. The 
fact that they succumb more quickly to the disease than older children 
makes proportionately large doses necessary. 

It has been urged against serums containing over 250 units per cubic 
centimetre that their use is apt to be followed by untoward effects, such 
as skin eruptions and local irritations. On the other hand, if the weaker 
serums are employed, such large amounts have to be given that very 
considerable swelling of the area in which the injection is given is pro- 
duced, and, of course, valuable time is lost before the whole dose is 
absorbed; whereas if serums containing high immunizing power are 
employed, the small dose is quickly absorbed. In urgent cases of nasal 
or laryngeal diphtheria the stronger serums are indicated, whereas in 
the more moderate cases the lower grades of strength may be used. 

In severe cases the antitoxin should be given intravenously, mixed 
with warm salt solution, and undiluted intramuscularly. 



DIPHTHERIA AND MEMBRANOUS CROUP. 745 

The author cannot too strongly urge upon the reader the vital 
importance of using antitoxic serum early and freely. The reports 
in which it has been condemned are imperfect and unreliable. It 
has been claimed by some persons that since the use of antitoxin 
more cases of complications or sequela? are met with than ever before. 
The reason is manifest, viz., that before antitoxin was used all the 
very malignant cases died, whereas a large percentage of these are now 
saved, and suffer from lesions which if antitoxin had not been used 
would have been fatal. Every patient who apparently suffers from 
the disease should receive this remedy, so potent for good and so 
lacking in harmful qualities even when given 10 non-diphthermc 
persons. The physician who can obtain the serum and does not use 
it is not doing the best thing for his patient. 

Much depends upon the early use of the remedy, for after degen- 
erative changes have taken place in the heart and kidneys the damage 
is done. Statistics show that in cases which receive the antitoxin on 
the first day the mortality is often only 3 to 5 per cent., whereas with 
each day of delay the percentage rises, so that when it is not given 
until the fourth day the mortality may be as high as 40 per cent. As 
the use of antitoxin does no harm, it should be employed in all doubt- 
ful cases of diphtheria without waiting for a bacteriological diagnosis. 

When the antitoxin is given, general improvement usually takes 
place in twelve to thirty-six hours, and the temperature falls. The 
spread of the membrane is arrested and its separation soon begins. 

The use of antitoxin for immunizing persons who have been exposed 
to infection should always be resorted to, and this is peculiarly true 
if the use of the Schick test reveals susceptibility. The use of 1000 
normal antitoxin units will usually produce immunity for three or 
four weeks. In the case of nurses or physicians, or children in insti- 
tutions this brief period of immunity militates against the employ- 
ment of antitoxin, the more so as the first dose may sensitize the 
individual to a second dose if needed because of further exposure. 
(See next paragraph.) If the Schick test (see page 747) is negative 
no immunizing treatment is needed but if it is positive diphtheria 
toxin (80 per cent, of the L+ dose) neutralized by mixing it with 1 
unit of antitoxin is to be injected, since it has been found that although 
this treatment results in the production of immunity more slowly than 
if antitoxin alone is used, nevertheless the immunity conferred lasts 
for many months. If the patient has been exposed to diphtheria the 
Schick test shows susceptibility antitoxin must be given in addition, 
as the prophylactic is too slow. The dose for adults and children is 
1 mil. repeated every five days for three doses. This so-called Diph- 
theria Prophylactic is now placed on the market in sealed bulbs and 
syringes. The dose is 1 mil. (1 c.c). 

In a small proportion of cases the injection of antitoxin serum is 
followed by the development, within a few hours or even after several 
days, of urticarial or erythematous rashes and swelling and pain about 



746 DISEASES. 

the joints. These symptoms are more prone to develop when high- 
potency serums are employed, and in very rare cases may be so severe 
as to be fatal. Indeed, a number of cases are on record in which 
death has ensued, the alarming symptoms consisting of sudden flush- 
ing and cyanosis of the face, severe dyspnoea, and rapidly developing 
unconsciousness with signs of pulmonary cedema. Death has taken 
place within five minutes of the injection. It is difficult or impossible 
to determine beforehand what cases will, because of idiosyncrasy, suffer 
in this manner, save that asthmatics and patients of a marked lym- 
phatic type seem more prone to it than others, but if a minute dose of 
antitoxin given intradermally, not hypodermically, results in a sharp 
local reaction this warns the physician that his patient is sensitized. 

Anaphylaxis does not depend upon the size of the dose given, and the 
hypersensitiveness of the patient lasts for an indefinite period in all 
probability. In animals it has been found to persist after three years. 

So far no method has been devised by which the desperate symptoms 
of severe anaphylaxis can be cured. Adrenalin has been used with- 
out any very good grounds for its employment, and without very much 
success. The drug which would seem to promise the most relief, so 
far as the pulmonary cedema is concerned, is atropine in full doses. 

Notwithstanding the startling effects in these cases, it is to be dis- 
tinctly understood and sharply emphasized that the number of these 
accidents has been so infinitesimal as compared to the hundreds of 
thousands of injections given during the last ten years, that no hesi- 
tation should be tolerated in the use of antitoxin in diphtheria except 
in the class of cases already referred to and under the conditions about 
to be named, for the danger of the disease is great and that of the 
injection is so small as to be negligible. Thus, in 100,000 cases, re- 
ported by Park, in which immunizing doses were given, only 1 death 
occurred and that was a child who had status lymphaticus. 

An important fact to be borne in mind is that the injection of antitoxin 
for the purpose of immunizing an individual who has been exposed to 
the disease, or for the purpose of combating an attack of diphtheria 
already present, produces after the lapse of several days a condition 
whereby the patient develops an extraordinary susceptibility to the 
serum, or, in other words, becomes sensitized to its effects, thereby 
producing a state in which the severe symptoms already spoken of 
may ensue when a subsequent dose is given. This condition, called 
anaphylaxis, does not take place if the doses of serum are given every 
few hours or even every other day for an indefinite period of time. 
It is only when a longer interval elapses between doses, amounting 
to seven days or more, that the patient is in danger of anaphylaxis 
when an injection is given. In other words, a patient who has received 
an immunizing dose of antitoxin, or a curative dose, is far more likely 
to develop evil symptoms after a dose given some time later than a 
patient who receives the antitoxin for the first time or in daily doses. 

The lesson to be learned from this in practical medicine is that 



DIPHTHERIA AND MEMBRANOUS CROUP. 747 

when a patient gives a history that antitoxin has been comparatively 
recently used, the physician should be cautious in the administration 
of the remedy. When a second attack of diphtheria is actually 
present, the danger to life is certainly far greater from the disease 
than from the possible development of anaphylaxis, but the fact that 
hypersensitiveness to antitoxic serum may have been developed by a 
previous injection must be carefully considered when the question of 
giving a dose for immunization arises. The rule would seem to be 
that where a child is thoroughly exposed to infection, an immunizing 
dose had better be given, but where the exposure is not so great as 
to lead the physician to the belief that infection is almost certain to 
occur, it may be well to avoid the use of a second immunizing dose 
for the reasons given. The physician is placed in the difficult position 
of determining whether there is greater danger to the child of an attack 
of diphtheria or of the development of the symptoms of anaphylaxis, 
and each case must be decided upon its merits. In orphanages and 
hospitals where a large number of children are gathered together, the 
certain mortality of an outbreak justifies the universal use of im- 
munizing doses, since the danger of the disease is infinitely greater 
than the danger of anaphylaxis. In private practice, however, the 
question is quite different and must be decided in each instance on 
its own merits. The use of the so-called Schick test will aid in deter- 
mining the course the physician should pursue, since it indicates those 
children which are susceptible to diphtheria and those that are practi- 
cally immune. This test consists in injecting into the skin of the fore- 
arm, not under it, about -^ part of the so-called minimum lethal dose 
of diphtheria toxin for a 250-gram guinea-pig. This is diluted before 
injection, with 3 minims (0.2) of salt solution. If the patient's blood 
contains 3V °f a un ^ °f antitoxin in each cubic centimeter, the child 
is immune and no effect is produced, but if it needs antitoxin to arti- 
ficially protect it a reddened and tumified area develops in from twenty- 
four to forty-eight hours and lasts from seven to ten days, and then 
becomes brownish and scaly. A pseudo-reaction consists in greater 
infiltration, is less sharply outlined and disappears in twenty-four to 
forty-eight hours. It does not scale. The method is perfectly safe 
and the toxin ready for the test can be obtained on the market in 
capillary tubes of toxin with a tube of salt solution. 

Great care as to the prevention of the disease is needful. All cases 
should be carefully isolated; children who have been exposed should 
be quarantined for fourteen days; persons in perfect health who have 
been nursing such patients should also be quarantined, for in the 
secretions of the throat diphtheria bacilli may be carried by an appar- 
ently healthy nurse to another patient. The nurse and physician 
should therefore gargle with saline solutions and follow this by anti- 
septic mouth washes (see Ethylhydrocuprein hydrochloride), using 
the greatest cleanliness as to the hair, hands, face, and clothing. 

The maintenance of the patient's strength during an attack of 



748 DISEASES. 

diphtheria is of great importance. Simple, easily swallowed, and 
easily digested food should be freely given, and plenty of water 
provided to allay thirst and flush the kidneys of poisons. Milk, 
predigested or plain, is useful, as is also properly made beef-tea (see 
Feeding the Sick); soft eggs, etc., are to be given; and if swallowing 
is difficult because of soreness or paralysis, then we must feed by the 
use of the soft-rubber nasal tube, inserted through the nasal cavities 
into the pharynx after being well oiled with albolene. (See Gavage, 
Part III.) Such a method of feeding may be resorted to in cases 
of inability to swallow arising from paralysis and consequent regurgi- 
tation; in coughing which prevents swallowing, as in tracheotomy cases; 
and in the vomiting which sometimes follows swallowing, but often 
does not follow nasal feeding. It is best to make any needful applica- 
tions to the throat before giving the food, in order to avoid vomiting. 

Feeding by the rectum may also be resorted to, and hypodermoclysis 
is not to be forgotten for the purpose of supplying fluid to the tissues. 

Tincture of the chloride of iron, quinine, and strychnine are of 
service to keep the kidneys active, to stimulate the heart and respira- 
tion, and to support the vital forces. The dose of the tincture of iron 
may be as much as 2 minims (0.1) every three hours, well diluted with 
water, to a child of four years. 

Steam set free in the air of the room is very useful as an adjuvant to 
local treatment, and the bronchitis-tent may be used in laryngeal cases. 

When the glands of the neck threaten to suppurate, ice-bags should 
be applied to the throat and pieces of ice .held constantly in the mouth, 
while the tincture of iron is pushed in as full amounts as possible. 

If suffocation is imminent, inhalations of oxygen are to be used and 
atropine or strychnine employed, and intubation or tracheotomy may 
be resorted to. 

During convalescence the patient should be kept at absolute rest in 
bed to avoid heart failure. 

Chlorate of potassium has been used purely empirically in the treat- 
ment of this disease, but it should never be given internally, as the 
kidneys are already overburdened, and this drug is not only useless 
when so given, but is in addition a renal irritant. Although the author 
has been criticized for this last statement, he is convinced of its truth. 
It tends to disorder the stomach and exercises no useful function 
whatever. 

DROPSY. 

Dropsy is to be regarded as a symptom (not as a disease in itself) 
which may arise from many causes, such as cardiac, pulmonary, or 
renal diseases, or it may depend upon obstruction, from various causes, 
to the normal flow of the blood and lymph through the vessels and 
tissues. Its existence is dependent upon so many causes of a still 
more indirect nature that it is almost impossible to notice all of them, 
but the following consideration of the subject will at least make clear 



DROPSY. 749 

some of the reasons for its occurrence and indicate the means which 
are to be taken for its relief. 

At the very start we are confronted by facts which seem para- 
doxical, but which are in reality quite reconcilable. These are, that 
low arterial pressure predisposes to dropsy, and that high venous 
pressure does likewise, or, in other words, that the cause of exudation 
on one side of the circulation is its prevention on the other. 

The explanation of these statements lies in a thorough under- 
standing of the physics of the circulatory system and its physiological 
function. It will be remembered that dropsical exudation takes 
place from the capillaries, and that the integrity of the walls of the 
bloodvessels and lymphatics depends upon normal nutrition, or, in 
other words, upon a proper blood-supply. As a consequence, dropsy 
may be due to poorly nourished vessels as much as to any other cause. 
The force exercised upon the column of blood as it is driven out 
by the heart into the aorta may be considered as the chief support of 
the capillary circulation, so that if the heart be weak the pressure 
falls in the arteries, and in consequence the rapidity of flow is de- 
creased in the capillaries, while, on the other hand, an increased 
cardiac activity hastens the capillary circulation. As the arterial 
pressure and force depend not only upon the heart force, but also 
upon the tonicity of the arteries which carry the blood-stream, it 
becomes evident that dilated arteries must lower blood-pressure even 
if the heart be strong, although practically the heart and vasomotor 
system generally fail or increase in tone together. We find, there- 
fore, that a weak heart or a relaxed artery tends to cause stagnation 
of the blood in the capillaries, and, having found that such stagnation 
tends to produce exudation, it is not difficult to understand why low 
arterial pressure aids in the development of dropsy. 

Having shown this to be true, let us turn to an explanation of the 
fact that a high pressure in the veins is productive of the same changes. 
Here the normal pressure is almost nothing, being much less than 
in the arteries, and considerably less than in the capillaries. The 
result of this is, that in health the blood flows rapidly from the high 
pressure of the artery to the low pressure of the vein, and passes 
through the small veins under a gradually decreasing pressure until it 
reaches the heart. Any obstruction to this venous flow must increase 
the venous pressure, and, the venous pressure being increased, the 
rapidity of flow through the capillaries must be decreased. The 
whole subject may be made more clear by the following example: 

Suppose that two iron tubes are connected at the ends by several 
lines of rubber tubes (the capillaries), and that water is flowing into 
the first tube, or the artery, under a pressure which is represented 
by the figure 100, while the resistance to the flow in the second tube, 
the vein, is represented by the figure 0. It at once becomes evident 
that the rapidity of the flow through the connecting rubber tubes will 
be very great, whereas if the pressure in the first or arterial tube is 



750 DISEASES. 

decreased to 50, the rapidity is decreased to one-half, or if the pressure 
in the second tube be increased to 50 instead of remaining at 0, the 
same change will occur; in either instance capillary flow is lessened 
and exudation is caused. This is a crude explanation of what may be 
called the mechanical pathology of dropsy. 

In cardiac disease dropsy is due to a weak heart being unable to 
supply the arteries with enough blood to maintain the normal pressure, 
or to a damming-up of blood in the venous system as the result of the 
imperfect emptying of the cardiac cavities. In the first instance low 
arterial pressure produces dropsy; in the second, high venous pressure 
has a similar effect. 1 

In renal troubles the dropsy depends more upon the lack of proper 
nutritive processes in the capillary walls and upon changes in the blood 
and blood-pressure than upon other causes. If the kidney is diseased, 
it may not be able to eliminate the proper quantity of liquids, which 
accumulate and finally escape into the tissues, while the same failure 
in renal function causes disease of the bloodvessels themselves, and 
often produces cardiac complications. 

Hepatic troubles cause dropsy by producing pressure upon the large 
bloodvessels going to the liver, and, in consequence, the exudate is 
generally confined to the lower limbs and abdomen. If the hepatic 
trouble be severe, some failure in the nutrition of the bloodvessels and 
changes in the quality of the blood may ensue. 

Pulmonary disease rarely causes dropsy unless the venous pressure 
is greatly increased and is productive of cardiac dilatation, or, as in 
phthisis, where the changes in the nutrition of the body involve the 
bloodvessel walls and the blood. 

Having spoken of these causes of dropsy, it remains to consider 
its treatment, which may be divided into two parts — namely, that 
directed to its removal after the liquid is poured out, and its relief 
or cure by direct attention to its causes. The means for the removal of 
the fluid are suitable to all cases, be the cause what it may, unless 
the dropsy be of renal origin. Whenever an accumulation of liquid 
takes place in the tissues, drugs or measures must be resorted to which 
will cause the emunctories of the body to get rid of it. We may 
employ elaterium in the dose of J grain (0.01), or elaterin in the dose 
of J grain (0.003), placed in the mouth and washed down by a little 
water, or the compound jalap powder may be resorted to in the dose 
of 20 to 30 grains (1.3-2.0), and to it may be added, to increase its 
efficiency, 15 grains (1.0) more of bitartrate of potassium than the 
official powder contains. These two remedies are particularly ser- 
viceable in renal dropsies, since the elaterium is supposed to aid in 
the elimination of urea by the bowel, while the cream of tartar in the 
jalap powder increases the action of the kidneys. 

The cream of tartar is not to be employed in cases of acute nephritis. 

1 For an explanation of these changes in the action of the muscle, valves, and cardiac 
action in heart disease, see the article on Heart Disease. 



DROPSY. 751 

Compound extract of colocynth may be employed in the dose of 5 to 15 
grains (0.3-1.0), according to the state and idiosyncrasy of the patient. 

All these remedies relieve dropsy by causing so great an outpouring 
of liquid from the bloodvessels of the intestine that the liquids in 
the tissues are taken up by the depleted bloodvessels to replace the 
loss through the action of the purgative. In other words, these purga- 
tives render the alkalinity of the blood greater by concentration, and 
absorption of fluid occurs by reason of the following physiological and 
physical facts: 

As is well known to every 7 physiologist, the passage through a blood- 
vessel of a salt solution of less than 0.7 per cent, causes an abstrac- 
tion of salts from the surrounding tissues by the circulating fluid, in 
order that the amount of salts in the vessels and tissues may be identical. 
At the same time the tissues become infiltrated with liquid. On the 
other hand, if the solution be stronger than the normal 0.7 per cent., 
the liquid leaves the tissues to enter the vessels, and the tissues in con- 
sequence shrink. 

When salines are given to relieve dropsy, they must be admin- 
istered in concentrated or saturated solution and on an empty stomach, 
total abstinence from the drinking of water being insisted upon until 
they have fully acted, for the reasons given in the last paragraph. 
For this reason they should be given an hour or so before breakfast. 
If these directions are not followed, this method of treatment is useless. 
(See Magnesium Sulphate.) 

The other means which we possess for the removal of dropsy are 
by way of the kidneys and skin. If the kidneys are hopelessly dis- 
eased, that pathway is almost useless; but if they are only passive or 
partly inactive, diuretics may be used to stimulate their secreting 
structure and to increase the leakage of liquid through them by increas- 
ing blood-pressure. Such patients should be placed almost entirely 
on a milk diet, and many of them will greatly improve under the use 
of buttermilk to the exclusion of other nourishment. Sugar of milk 
may be employed as an active diuretic. (See Sugar of Milk.) 

It has been proved that in acute and chronic parenchymatous 
nephritis the kidneys are often unable to eliminate the daily quantity 
of chlorides which they excrete in health. It is considered by many 
that the resulting accumulation of sodium chloride in the tissues requires 
an excess of water to maintain the normal molecular concentration, 
and that this in return results in dropsy. Further, it has been proved 
that if these cases are placed upon a diet which contains less than 
45 grains (3.0) of salt a day, they develop diuresis and the dropsy 
decreases in some instances because the tissues are no longer loaded 
with chlorides. As milk is low in chlorides this may be one of the 
reasons why it is useful as a diet in nephritis. 

Often the kidneys will be found inactive because, owing to conges- 
tion from cardiac trouble, they cannot act. Under these circumstances 
digitalis, in 5- or 15-minim (0.30-1.0) doses of the tincture, given 



752 DISEASES. 

three times a day, will be of value, and its efficacy will be increased 
by the addition of 1 minim (0.06) of the tincture of cantharides if the 
renal lesion is exceedingly chronic or mere torpidity exists. Digitalis 
and squill, in pill form, as follows, may be used: 

1$ — Pulveris digitalis . . . . . . . . gr. xx (1.3). 

Pulveris scillse gr. xx (1.3).; — M. 

Fiant pilulae No, xx. 

S. — One every five hours. 

Or digitalis and calomel may be employed in pill form in renal and 
cardiac dropsies. Apocynum cannabinum is also a useful drug in 
this state. (For another useful formula see article on Heart Disease.) 

Caffeine is also a useful diuretic, particularly in torpidity of the 
kidney, as it stimulates the secretory epithelium, thus eliminating urea 
and other effete matters, and increases the passage of liquids by the 
increased blood-pressure which it produces. 

Pituitrin, given in the dose of 15 minims (1.0) hypodermically or by 
the mouth twice a day, is often an efficient diuretic in cardiac dropsy. 
No drug should ever be given hypodermically in dropsy of a general 
character, as it will not be absorbed from the water-soaked tissue with 
any rapidity, if at all. 

The chief means of relief to be resorted to in cases of ascites is tapping. 
Efforts to remove effusions in the peritoneal cavity by medicinal 
measures are rarely followed by success. In reality, tapping is far 
less heroic treatment than purgation, and the old theory that it is 
dangerous has been disproved. It has been found that tapping not 
only removes the fluid, but may in certain cases of hepatic cirrhosis 
produce a permanent cure after from one to twenty or more operations. 
In performing tapping, the patient is to be placed in a sitting or semi- 
recumbent position, and directed to evacuate his bladder, so that there 
will be no danger of this viscus being injured by the trocar. The 
skin of the abdomen in the middle line one or two inches below the 
umbilicus is next benumbed by the subcutaneous injection of a few 
drops of a solution of eucaine or cocaine. The physician then takes a 
trocar and canula, at least four inches long, and pushes it through the 
abdominal wall until the decrease in resistance he knows the point 
has entered the abdominal cavity. It is well to have a broad abdomi- 
nal bandage placed around the belly, so that an assistant by pulling 
on its ends may support the belly-walls when they become relaxed by 
the escape of the effusion. As a rule not more than one-half or three- 
fourths of the liquid should be removed at one sitting, as its entire 
removal may be followed by collapse or by rapid flowing out of fresh 
transudate. 

The value of iodide of potassium in cases of ascites is not to be 
forgotten, but it must be given cautiously if renal disease is present. 

Dropsical patients can sometimes be relieved of large amounts of 
fluid by elevating the head of the bed and introducing into each leg a 
trocar to which is attached a rubber tube the lower end of which is 



D YSMENORRHCEA . 753 

placed in a bottle, one of which is hung on each side of the bed. When 
this plan fails and the tenseness of the skin in the lower extremities 
causes danger of local sloughs, several free incisions for the escape of the 
liquid should be made, the limbs being encased in sterilized gauze to 
absorb the liquid. 

DYSENTERY. 
(See Diarrhoea.) 



DYSMENORRHEA. 

The existence of dysmenorrhea depends upon so many conditions 
that the treatment employed in one case often fails to produce 
success in the next. This is not the place for a consideration of the 
surgical measures adopted for the cure of this symptom, and only the 
medical treatment will be spoken of. 

When dysmenorrhcea results from the taking of a cold, and is 
accompanied by uterine congestion and irritability, the following 
measures are particularly valuable, and may do good in many cases 
depending upon other causes: The patient should take a hot sitz- 
bath, and immediately get into bed as soon as the buttocks are dried, 
being well covered, while in the tub and afterward, by a blanket. A 
turpentine stupe is now to be used (see Turpentine), and 10 grains 
(0.60) of Dover's powder to be administered unless an idiosyncrasy 
toward opium is known to exist, when a half or a fourth of this amount 
may be employed or 10 grains (0.60) of Tully's powder employed. 
Often when the attack is accompanied by constipation a purgative 
dose of Epsom salt is of service. 

If the- pain is persistent and severe, a suppository of 1 grain (0.06) 
of the extract of hyoscyamus may be inserted into the rectum, or in 
other cases belladonna ointment smeared over the os uteri will be 
found of service. The latter method is generally impracticable and 
is rarely resorted to. Very commonly full doses of tincture of hoscya- 
mus is of service in relaxing the spasm of the cervix and of the uterine 
fundus. 

Some practitioners resort to the use of opium at each epoch, and 
keep the patient partially narcotized until menstruation is passed. 
This is unjustifiable since the physician is simply dodging effective 
treatment of the trouble and predisposing the patient to future attacks 
by reason of the constipation and the resulting habit which is almost 
sure to appear after the repeated employment of opiates. 

When the dysmenorrhcea is due to obstruction of the cervical canal 
by organic changes or flexions, these conditions must, of course, be 
relieved before a cure can be expected, and the medical treatment 
can be directed only to alleviation of the pain. Divulsions or slow 
or rapid cervical dilatation should be carried out by the use of instru- 
ments. 

48 



754 DISEASES. 

In neuralgic dysmenorrhcea, dependent rather upon nervous dis- 
order accompanying menstruation than upon menstruation itself, 
measures directed to the improvement of the nervous system and the 
nutrition of the patient are necessary. (See Rest Cure.) These cases 
generally occur in nervous, anaemic women run down by excessive 
dancing or other gayety or by the bearing and care of a large family 
of children. 

A course of strychnine or quinine and iron in small doses is often 
beneficial in these cases, and horseback exercise between the men- 
strual periods, out-of-door life, and avoidance of excessive dancing 
and exhausting exercise are to be ordered. 

Cannabis indica and gelsemium are often of great service, both as 
cures and alleviators of the pain, and antipyrine, acetanilide, and similar 
drugs may be resorted to while the attack lasts if it be neuralgic. 

Sometimes bathing the loins, between the periods, with alternate 
dashes of hot and cold water may do good in atonic patients. In 
other cases a hot vaginal douche at the onset of pain may give 
relief. 

When the pain seems to be greater than the patient can bear, enough 
ether or chloroform should be given by the physician, by means of 
inhalation, to produce the primary stages of relaxation. Chloral 
and other drugs capable of causing a habit are to be carefully avoided 
for obvious reasons. 

DYSPEPSIA. 

(See Indigestion.) 

DYSPNCEA. 

Shortness of breath, or dyspnoea, arises from asthma, cardiac weak- 
ness, from the accumulation of fluid in the chest, from the involve- 
ment of the lungs by any disease process in such a way that respiration 
becomes impaired, or it is produced by indigestion, or, finally, by the 
encroachment on the lungs or chest-walls of morbid growths. It may 
also be due to ursemic or diabetic toxaemia. 

Each of these states must be removed to effect a cure, but it is only 
of the relief of the symptoms that we will speak. 

In old persons who suffer from dyspnoea the result of bronchor- 
rhoea, when a large amount of liquid fills the bronchial tubes and 
shortness of breath follows exertion, strychnine or caffeine is the best 
remedy. Its value depends upon its powerful influence over the respira- 
tory centres, on which it acts, as a stimulant; and as these cpv™ 
very commonly also have dilatation of the right side of the heart, 
with consequent cardiac enfeeblement, strychnine is of additional 
service through its influence upon the circulation. These individuals 
are not to be given opium or its alkaloids or any sedative drugs, as 



EARACHE. 755 

such medicines, while giving temporary relief from cough, only serve 
to depress the respiratory apparatus and cause an accumulation of 
liquid mucus in the chest as a result of the prevention of cough and 
expectoration. The cases in which opium, or morphine, does good 
are those in which, through nervousness or functional nervous dis- 
order, the respiratory cycle is imperfect, and, above all, in those in- 
stances in which dyspnoea occurs as the result of cardiac disease. In 
these cases the attacks of oppression and suffocation can often be 
entirely prevented by the use of J to \ grain (0.008-0.015) of morphine, 
given every night or each night and morning. If these doses fail, 
larger ones may be cautiously used. Hyoscine, instead of causing 
sleep, nearly always makes these cases worse. 

Sometimes a little carbonate of ammonium is useful as a respiratory 
and cardiac stimulant in cases of dyspnoea. 

Dry cupping applied over the back of the chest may also be serviceable 
when shortness of breath from cardiac or pulmonary trouble is present. 

In cases of dyspnoea due to emphysema and pulmonary inflam- 
mation of a chronic type, or in those persons who take cold on the 
slightest exposure, particularly after attacks of asthma, arsenic is 
useful if continuously employed. 

If pleural effusion be present, relief of a positive and lasting nature 
can only be obtained through aspiration, or, in other words, by the 
operation known as paracentesis thoracis. 



EARACHE. 

Earache may arise from a great number of causes, all of which 
are, practically speaking, inflammatory. The pain may be the result 
of acute or chronic inflammation of the middle ear, with a serous or 
purulent exudate, or of furunculosis of the external auditory canal. 
In other cases an eczema of this part is very painful. 

The treatment of an acute earache is systemic and local, the 
former being based on the general rules governing the management 
of inflammatory processes, the latter according to the area involved 
and the cause of the trouble. Cardiac sedatives are indicated, but 
quinine is distinctly contraindicated, as it tends to cause aural con- 
gestion. In the general treatment several leeches may be placed in 
front of or behind the ear, and heat in a dry form is to be applied to 
the head on the side affected, by means of a hot- water bottle or water- 
bag. Poultices, oil and laudanum, and similar applications are not to 
be resorted to, as they may ultimately produce too extensive suppura- 
tion, and they do not always give even temporary relief, but tincture 
of belladonna and tincture of opium in equal parts carefully warmed 
may be dropped in the ear in the dose of 5 to 10 minims (0.30-0.60) 
when necessary. 

A very efficient means of relieving the pain is to irrigate every 



'56 



DISEASES. 



. . . gr. x (0.60). 

. . . gr. xij (0.8). 

. . . gr. x (0.60). 

q. s. ad fgiij (90.0).— M, 



Fig. 130. 



hour or two the ear by means of a fountain syringe with normal salt 
solution used as hot as can be borne (Fig. 130). 

If a cold in the head is present, and with it acute myringitis, it is 
important to establish a free opening through the nostrils, particularly 
if the middle ear also is involved, in order to clear the orifice of the 
Eustachian tube. This is to be accomplished by dropping into each 
nostril adrenalin chloride (1 : 5000 solution) or 1 to 3 minims (0.06-0.20) 
of a 4 per cent, solution of cocaine, and, as soon as the engorged mucous 
membrane is anaesthetic and shrunken, to use the following solution 
in an atomizer with a fine spray attachment: 

1} — Acidi borici 

Sodii chloridi .... 
Sodii boratis ..... 

Aqua? rosae 

S. — Use as a spray. 
This should be followed by a spray of menthol and albolene, 3 grains 
to the ounce (0.20:30.0), in order that the menthol may prolong the 
effect of the cocaine and prevent secondary congestion. This is to 
be followed by inflation of the Eustachian tube with a Politzer air- 
bag. Only in most obstinately painful cases of acute middle-ear 
catarrh is paracentesis of the drum to be performed. 

Should true septic otitis media develop and drainage of the middle 

ear become impossible through block- 
ing of the Eustachian tube, then the 
physician must very gently irrigate the 
external auditory canal with as hot 
water as can be borne, and render it 
aseptic by insufflations of boric acid 
powder. These irrigations should be 
frequently practiced, and if the pain 
persists and the tympanic membrane 
begins to bulge, paracentesis must be 
performed in the most bulging part 
of the lower quadrant. After the 
paracentesis needle is withdrawn the 
discharge should be allowed to flow 
freely. The canal is then to be well 
irrigated with hot 1:2000 perman- 
ganate of potassium or hot carbolized 
water (1 :50), and as the discharge is constant a thin piece of sterilized 
gauze should be inserted and allowed to act as a drain (not as a 
packing) and removed as often as soiled. 

In a case of eczema of the ear, hot irrigation, followed by the appli- 
cation of powdered iodoform, is perhaps the best application for 
temporary treatment. In furunculosis of the ear hot irrigations and 
free incision, with an iodoform dressing, are useful. 

When foreign bodies cause the pain, they are best removed by 
repeated and gentle syringing with hot water. Forceps are danger- 
ous instruments in the hands of a novice treating the ear. 





Aural irrigator. 



ECZEMA. 757 

In earache due to neuralgia a small compress wet with chloroform 
may be applied to the skin in front of and behind the ear. 

ECZEMA. 

This is probably the most common form of skin disease which the 
physician is called upon to treat, with the exception of acne. 

Dermatologists divide it into many forms and stages, but in this 
book a consideration of its forms is out of place, and only the treatment 
for its stages is proper. 

In the first place, it may be stated that the treatment is a quadruple 
one — namely, dietetic, hygienic, external, and internal. 

In regard to diet, the patient should be told to avoid salty foods, 
such as salted fish or pork and corned beef; greasy foods, such as bacon 
and fried dishes; pastry and cheese. At most only moderate amounts 
of wine and beer can be taken, and foods difficult of digestion are to be 
stricken off the bill of fare. 

In the way of hygienic measures, fresh air, the avoidance of sedentary 
habits, horseback exercise or walking are to be recommended. 

External treatment is the most important of the two measures in 
which drugs are employed, and its course is perhaps best described 
by taking a case of ordinary eczema as an example and treating it 
through its entire course. 

In the early stages of an acute eczema, when the process is very 
active and the erythematous reddening is merging into the forma- 
tion of vesicles or pustules, with the formation of large scabs, no 
application is better than oxide-of-zinc ointment, thoroughly applied 
night and morning. If the eczema be situated upon the scalp, the 
hair must be invariably clipped short or shaved off in such a way as 
to prevent the gluing of the hair into a mat by reason of the discharge. 
The ointment may be smeared over the part or applied on a piece 
of lint in a thick layer. Nearly always the ointment should be used in 
conjunction with black wash (calomel 1 drachm [4.0], lime-water 1 
pint [480.0]), which should be applied twice a day, just before the 
zinc ointment is resorted to, by means of a swab or sop, and 
allowed to dry. In other cases the powdered oxide of zinc is dusted 
over the part if the discharge is very watery and profuse, or the 
following ointment, recommended by McCall Anderson, is very 
efficacious : 

ty — Bismuthi oxidi gj (30.0). 

Acidi oleici puri g v iij (240.0). 

Cerse albae giij (90.0). 

Petrolati gix (270.0). 

Olei rosse l^v (0.3).— M. 

Fiat unguentum. 

S. — Apply to the part affected. 

As the quantities of this prescription are large, they may be reduced 
one-half for use in localized eczema. 



758 DISEASES. 

.Where the proliferation of cells and the secretion are very profuse 
it may become necessary to remove the crusts before the local remedies 
tan reach the skin, and for this purpose poultices may be used; or, if 
the disease be on the face, the parts should be anointed with olive oil, 
containing 1 or 2 minims of phenol to the ounce (0.06-0.12 : 30.0), 
to soften the crusts, which are readily removed in a half-hour by 
the use of castile soap and water. The soap and water are not to be 
used if the inflammatory area is very angry looking. Whenever itching 
is an annoying factor, the parts should be protected by lint smeared 
with some simple ointment, which may be carbolized, both for its anti- 
septic and local anaesthetic effect. English and American dermatolo- 
gists use what is known as liquor carbonis detergens very largely in 
the acute stages of eczema. It should not be used pure, but diluted 
in such a way that for each 4 ounces (120.0) of water 2 drachms (8.0) 
of the pure liquor are present. Liquor carbonis detergens is made 
by taking 9 ounces (270.0) of tincture of soap-bark (quillaia-bark) 
and 4 ounces (120.0) of coal-tar, mixing and allowing them to digest 
for eight days, after which the mixture is filtered and is then ready 
for use. 

In infants light splints may be put on the arms to prevent the child 
from scratching the parts, and if there is a free outpouring of serum the 
following lotion may be dabbed on the inflamed area every few hours : 

B— Phenolis ITtxv (1.0) 

Ichthyolis 3j (4.0) 

Zinci oxidi 3ij (8.0) 

Magnesii carbonatis 3ij (8.0) 

Liquor, calcis fgiv (120.0).— M. 

S. — Use locally. 

If crusts are present the following may be placed on a piece of lint, 
in which holes are cut for the nose, eyes, and mouth, tapes being 
attached to the edges of the lint, so that it can be held on the child's face 
by tying them back of the head: 

1$ — Acidi salicylici gr. iv (0.3) 

Ichthyolis . gr. xx (1.3) 

Zinci oxidi gr. xxx (2.0) 

Unguent, aquae rosse Bij (60.0). — M. 

When the disease has passed from the acute, active inflammation 
of the first stage to the subacute form of the second stage, applications 
of a mildly stimulant character are necessary. Before this the aim 
has been to soothe the parts; now they must be excited to normal 
activity. For this purpose resorcinol in the proportion of 2 to 30 
grains to the ounce (0.12-2.0 : 30.0) of lard, according to the severity 
and induration of the lesion in the skin, may be used. Stelwagon 

1$ — Unguenti picis liquidi 3J (4.0). 

Unguenti zinci oxidi 5vij (28.0). — M. 

S. — Apply to the parts. 






EMISSIONS. 759 

Where the disease is chronic and very persistent, and sluggish or 
atonic in its course, still more powerful remedies are necessary, such as 
salicylic acid, tar, or tincture of green soap used with hot water until 
the skin beneath is bared, dressing this by means of zinc ointment or 
resorcinol ointment, 2 to 10 grains to the ounce (0.12-0.00:30.0), 
spread on a cloth. The salicylic acid should be used in the propor- 
tion of 30 to 60 grains to the" ounce (2.0-4.0:30.0) of lard, while the 
tar is used in the form of the pure official tar ointment. 

In seborrheic eczema, where the secretion is greasy and diy, and 
complicated, if wrongly treated, by oozing and the pouring out of 
serum and the formation of cells which form crusts, the following pre- 
scription is of value: 

1$ — Resorcinolis gr. x vel xx (0.60-1.3). 

Pulvis amyli, 

Unguenti zinci oxidi aa 5ij (8.0). 

Petrolati §ss (16.0).— M. 

S. — To be applied after removing the scabs by the use of a lotion composed of 
1 part of bay rum and 3 parts of water. 

The internal treatment is directed to the cure of any disordered 
function which is present, such as dyspepsia (see Indigestion), hepatic 
torpor, general debility, anemia, scrofulosis, inanition, constipation, 
gouty diathesis, or renal insufficiency. The gastric disorder is to 
be relieved by the use of hydrochloric acid and pepsin; the hepatic 
torpor by mercury, podophyllin, or, better still, by freshly prepared 
undiluted nitrohydrochlorie acid added to water; the debility by 
tonics, such as cinchona, cod-liver oil, strychnine, and bitters; the 
anaemia by iron, and, if scrofulosis exists, by the syrup of the iodide 
of iron. Constipation is to be cured by the use of proper foods and 
laxatives, and the gouty tendency counteracted by the employment 
of the salicylates, lithium citrate, colchicum, or potassium iodide. If 
the kidneys are at fault because of torpidity, the diuretic potassium 
salts, such as the citrate, are indicated. Arsenic is never to be used, 
except in those instances where the skm is very dry, and where, by 
improving digestion and through its alterative power, it may do good. 
In the chronic forms of dry eczema or those depending upon an atonic 
state of the trophic nerves of the skin, arsenic is of great value in the 
form of Fowler's solution, or arsenic trioxide may be given. 

EMISSIONS. 

Seminal emissions occur as the result of sexual abuse, whereby a 
condition of hyperexcitation of the nerve ceils in the spinal cords and 
the nerves of the genitalia is developed, or they are due to peripheral or 
centric irritations, which reflexly irritate the genitalia or their nerves, 
and to a number of other similar causes. These emissions also occur 
with some periodicity in normal males who are continent and chaste, 
and under these circumstances are not to be interfered with by treat- 
ment unless the emissions become excessive. 



760 DISEASES. 

The former types are, however, proper for medical treatment, and 
their cure consists in the avoidance of unchaste literature and lascivious 
thoughts during the waking hours, and the use of such spinal and 
cerebral sedatives that the centres governing the ejaculations of semen 
may be calmed, and so quiet a sleep produced that erotic dreams are 
avoided. The patient should sleep on a hard hair mattress, not be too 
heavily covered, and should avoid sleeping on his back, as this causes 
an undue blood-supply to the spinal centres, and consequent stimula- 
tion and ejaculations. Sometimes hard bodies, such as spools, are 
tied around the loins, so that lying on the back will cause so much dis- 
comfort that the patient awakes and turns on his side. The drugs to 
be used are bromide of potassium or sodium in 20-grain (1.3) doses at 
bedtime, or chloral may be taken in the same amount. Hyoscine 
is certainly of value in the dose of y^- grain (0.0006). Sometimes a 
warm sitz-bath or general bath before going to bed is of service. In 
other cases, where atony is the cause of the trouble, the physician 
should recommend cold sponging of the perineum and loins night and 
morning. 

In the cases in which emissions come on as the result of continence, 
and become excessive, the remedies just named are to be tried, but 
do not effect any permanent cure unless used until sexual power is 
seriously depressed, so that it has been the custom of many physicians 
to recommend "marriage," which the patient may interpret in its 
legitimate light or not as he pleases. 

It is worthy of note that all irritations of the urinary bladder and 
other parts of the genito-urinary system should be removed, and it 
is often of value to administer citrate of potassium in 20-grain (1.3) 
doses, in water, three times a day, to render the urine non-irritating 
and alkaline. Stimulating foods and drinks are to be interdicted, 
and condiments, such as pepper and mustard, avoided. 

Sometimes, when the emissions are caused by genital atony, strych- 
nine and arsenic are of great service if given in full dose. 

In many of these cases it is the duty of the physician to treat the 
moral state of his patient as well as to give medicines. Many per- 
sons, believing that emissions are always an evidence of disease, read 
books on such subjects which are sold by quacks, and soon find their 
way to the hands of these persons. A few sensibly consult a regular 
physician. Half the treatment in these instances consists in assuring 
the patient that he has nothing to worry about, and in making him 
feel that the physician is his friend and worthy of all confidence and 
complete belief. 

ENDOCARDITIS. 

Endocarditis may be acute or chronic. Acute endocarditis occurs 
as a result of some general infection which is usually rheumatism. 

In acute sthenic endocarditis tincture of aconite, 10 minims (0.65) 
given every hour until the physiological symptoms of its influence 



EPILEPSY. 761 

are present, is useful, or with equal efficacy may be employed the 
tincture of veratrum (10 to 15 minims [0.60-1.0*]). In most cases 
it is better to apply an ice-bag over the heart. Aconite and other 
depressants are contraindicated if the heart is at all feeble, and 
should only be used in the earliest stages of the disease. The most 
important measure is absolute rest upon the back. This must be 
insisted upon. If the cause of the disease is acute rheumatism, a 
number of small blisters placed on the prsecordium will be of value 
in preventing pericardial complications. (See Acute Rheumatism.) 
If the disease becomes ulcerative, supporting treatment, consisting 
chiefly in the use of good food and the free administration of the 
tincture of the chloride of iron, should be resorted to. (See Vaccines.) 



EPILEPSY. 

The disease known as epilepsy is probably the most disheartening 
condition as to treatment that the physician has to deal with, since it 
often resists the influences of all the standard remedies, and drives 
the practitioner from drug to drug in the hope of finding one which 
will be at least alleviating in its effects. For this reason the author 
has in this article included many of the drugs which are rarely used, 
as well as those generally recognized as useful in its treatment, in 
order that the physician may try every remedy of any possible value. 
In the treatment of epilepsy the fact must be borne in mind that the 
convulsions are the result of a lack of nervous control or balance. In 
idiopathic epilepsy there exists a state of impaired nervous equilibrium, 
with the result that explosions of nervous energy take place from the 
motor cortex of the cerebrum. These cases almost always develop 
in childhood and are dependent upon a congenital defect. A careful 
examination of them will nearly always reveal signs of their not being 
perfectly balanced mentally and physically. At the same time epilepsy 
is not a disease of idiots by any means. Often sufferers from it are 
remarkably clever, at least for many years. It is evident that in cases 
such as these the physician cannot hope to cure the patient perma- 
nently, although by proper feeding, iiygienic measures, and suitable 
drugs and tonics he may diminish the attacks very greatly. So, too, 
by removing causes of peripheral irritation he may diminish the fre- 
quency of the attacks, but he cannot eradicate the underlying nervous 
instability. If the condition arises in adult life, it is in the great major- 
ity of cases due to syphilis, to brain tumor, or to injuries of the skull. 
Under these conditions the prognosis and therapeutic possibilities are 
better than in the type just described; but if the fits have lasted for any 
length of time, so that a state of instability of the cerebral cells has 
been established, the condition may be irreparable, even if the treatment 
be most skilful. 

So far as drugs are concerned, the most valuable remedy in use for 



762 DISEASES. 

the relief of epilepsy is bromide of potassium, although other bromine 
salts will be mentioned later. 

Bromide of potassium is not a specific, but many cases prove that 
the remedy gives relief when it is used in a suitable manner, and in 
a large number of instances the seizures are so decreased both in vio- 
lence and frequency that its use may be said to be indicated in almost 
every case of the disease at some period in its course. In a very 
small minority, however, it signally fails. 

The doses to be used vary to a considerable extent with the salt 
employed, and depend upon the character of the disease and the tem- 
perament and physique of the patient. The greater the duration of 
the disease, the greater is the difficulty in effecting relief, and the 
length of time during which the patient has been epileptic should 
therefore be most carefully reckoned before the treatment begins. 
Further than this, the frequency and severity of the attacks are to be 
looked into, and these points are really more important than the actual 
duration of the ailment; since if a man has only one fit every six 
months for twenty years his condition is far less serious than if he has 
a history of three or four fits a day for one year. Again, the character 
of the attack, as to its violence, may be the most important fact to be 
regarded, for if it is violent enough to endanger life, remedies must be 
pushed even beyond the point of tolerance. The writer once heard 
a celebrated physician cause much amusement among his auditors 
by detailing an instance of an epileptic who was getting well, and 
would have recovered if he had not died. His explanation was, that 
the man was syphilitic, and was receiving moderate doses of iodide 
and bromide of potassium, which were slowly benefiting him, and 
would have cured him had not a single severe fit produced death in 
the meanwhile. 

Another point to be considered is the condition of the digestion, 
which the bromide of potassium is peculiarly liable to disorder, and 
which is sometimes so disturbed as to necessitate the administra- 
tion of the drug by the rectum in serious cases. Females generally 
require smaller doses than males, and children of both sexes do not 
require as large quantities as adults. The dose to be used in the 
beginning of the treatment in moderate cases is but 10 grains (0.60) 
thrice a day; and while this may seem a very small quantity, it will 
be found that it can be rapidly increased in amount without causing 
the gastric distress produced by the sudden use of larger doses. Each 
day an additional 10 grains may be added, until at the end of a week 
the patient is taking 80 grains (5.3) in each twenty-four hours. There 
are very few cases which will not become saturated with the drug 
if this is done, and there are very few in which a more rapid arrival 
at bromism is needed. If, however, the patient has become able to 
stand large amounts by the prolonged use of the drug, the amount 
given is not to be governed by grains, but by physiological effects, and 
it may be pushed to any amount which is borne without distress. 



EPILEPSY. 763 

Full doses of the bromides, particularly in epileptics of an advanced 
type, sometimes cause maniacal outbursts in place of the epileptic 
attacks. In other instances the patients become morose and homi- 
cidal. (See article by author in Therapeutic Gazette, June, 1897.) 
Cases are on record in which the persistent use of larger doses of 
the bromides has resulted in bronchitis with profuse and dangerous 
exudation, causing suffocative bronchitis. 

There is one more point to which attention must be called, and that 
is the fact that when the bromides are taken for any length of time 
they produce bromism, which in its moderate or severe forms pro- 
duces a mental condition closely allied to that seen in old, chronic 
epileptics. This condition of the mind should never be overlooked, 
and the ordinary mental changes of epilepsy are greatly aggravated by 
its constant and careless administration. (See Bromide of Potassium.) 

Recently European physicians have endeavored to aid the rapid 
saturation of patients by the bromides by depriving them of common 
salt, thereby causing the salt-starved system to absorb greedily the 
bromide of sodium. It is doubtful if this plan is justifiable. 

In chronic epilepsy, with regularly recurring fits, the greatest good 
is obtained by pushing the drug in ascending doses for one week, 
and then for the succeeding week only enough is given to preserve 
the general effects of the medicament. By doing this the stomach 
gets a rest and the appetite is not greatly interfered with. For obvious 
reasons where the attacks occur only every two weeks this is a particu- 
larly useful method. 

As regards the time of day when the drug is to be taken, there can 
be no doubt. Some writers have directed that it shall always be 
taken before meals, but this is entirely lacking in advantage and 
decidedly fruitful of harm. Drugs which are given with the object 
of affecting the general system should be taken after meals, not before, 
and it is only when a local gastric effect is desired that they should 
be given on an empty stomach, particularly when the substance is so 
depressing as a salt of potassium. If taken after meals, the appe- 
tite is not decreased, but there are few who can take a dose of 10 or 
20 grains (0.60-1.3) of bromide of potassium before breakfast without 
suffering from indigestion. 

If the attacks have a distinct periodicity, which is rare, or can be 
foretold for as long as two hours beforehand, the remedy may be 
taken in a large dose only at this time, and but a few grains given in 
the intervals; and if the attacks are severe, the physician should not 
hesitate to use large doses by the mouth and by the rectum on the 
day of the attack. 

It has been held by some that the drug should be taken in minute 
doses, frequently repeated, in order to keep the patient constantly 
under its influence. This is an example of therapeutic ignorance, 
because the bromides are slowly eliminated, and this frequent admin- 
istration possesses the disadvantages of being inconvenient, annoying, 
and apt to disorder the stomach. 



764 DISEASES. 

A very important point to be borne in mind is that the drug often 
seems to have produced almost a cure, and this results in carelessness 
in the regularity of administration. The patient should be impressed 
by the fact that every day passed without a fit is a step forward, and 
that every fit carries him many steps backward. He should also be 
directed to use the drug, in moderation, for at least three years after 
all fits have ceased, and to watch after that time for the slightest sign 
of their return. The quantity taken each day should be gradually 
decreased, not suddenly stopped. 

Before passing on to the discussion of the employment of the other 
bromides, and the conditions produced by the excessive dosage of all 
of them, we may place our use of these compounds in epilepsy on a 
scientific footing. It is now generally recognized that the seizures 
known as epilepsy arise from the cells in the cerebral cortex, and 
there can be no doubt that the bromides act very powerfully upon 
the cerebrum in the higher animals, decreasing the irritability of 
the motor centres in these regions to a very great extent. Not only 
is this pointed to by clinical facts, but the researches of Albertoni 
prove beyond all doubt that such is their action. This investigator 
found that the administration of a single dose of the bromide of potas- 
sium so lessened the excitability of the motor cells in the cortex cerebri 
that much stronger stimulation was necessary in order to cause response 
in the limbs than was normal, and that it was difficult to produce 
epileptic attacks by means of electrical stimulation of the motor areas 
even when currents were used very much stronger than those which 
commonly produce such a result. He also found that this lessened 
irritability was increased still further if the drug was given for several 
days beforehand in such doses as thoroughly to impress the organism. 
It is therefore evident that the bromides act directly on the cortical 
areas, calming the tendency to explosions of nerve-force. 

The bromides of gold, iron, lithium, nickel, and ammonium have 
all been used in epilepsy with good results, but, except in certain in- 
stances, they fail to act as well as those of strontium, sodium, and 
potassium, unless given in large doses. Bromide of sodium and of 
strontium are not by any means so apt to disorder the stomach, and 
are preferable in some cases on this account. They possess no other 
advantage. 

The bromide of ammonium is quite irritant and disorders the 
stomach very readily. It ought always to be used, when used at all, 
with other salts, the ammonium salt acting only as an adjuvant. 

Several clinicians have tried hydrobromic acid, but it is very much 
more apt to derange digestion and to produce vomiting than any of 
the salts. The dose of the dilute acid is \ to 3 drachms (2.0-12.0) in a 
tumblerful of sweetened water. 

There can be no doubt that in some instances what is known as the 
mixed treatment is very useful. This consists most commonly of a 
prescription in which the bromides of potassium, sodium, and ammo- 



EPILEPSY. 765 

nium take part. Why this combination acts better than any one of 
the salts alone is unknown, but it is certainly a clinical fact. 

Bechterew has recommended the joint use of the bromides with 
adonis vernalis in epilepsy as follows : 

1$ — Potassii bromidi 5iij (12.0). 

Infusi adonis vernalis f oiv (120.0). 

Aquae destillatae q. s. fgvj (180.0). — M. 

S. — A dessertspoonful three times a day. 

Sometimes codeine is combined with this prescription. 

Within the last few years it has been claimed by Flechsig that the 
use of opium for a long period of time is useful in the treatment of 
epilepsy. He gives the opium in ascending doses during a period of 
six weeks, beginning with \ grain (0.015) three times a day, and going 
as high as 5 grains (0.30) three times a day. This method decreases 
the frequency and severity of the fits for several months in some cases, 
but does not cause a cure. It succeeds best in old cases and is not 
useful in recent ones. 

In still other cases digitalis, when used along with one of the bro- 
mides, seems to produce favorable results. Indeed, digitalis has for 
years been used alone in epilepsy with fairly good results, and should 
always be used in obstinate cases. In 'petit mal, in which bromide 
of potassium when used alone so often fails, it is useful, and several 
English writers, notably Gowers, assert that its best effects are seen in 
cases of nocturnal epilepsy. Why this is the case no one knows, 
and it would seem doubtful whether it is more beneficial in nocturnal 
attacks than in others. 

Another combination very much employed and lauded is bromide 
of potassium with belladonna, the mydriatic being almost useless 
alone, although of great antiquity in its use in epilepsy. Like the mix- 
ture of digitalis and bromide, it succeeds very frequently in petit mal 9 
and, indeed, seems to be much more successful than the digitalis, but 
its mode of action is exceedingly doubtful. As the drug acts even 
more powerfully upon the nervous system than upon the circulatory 
apparatus, it has been thought that its influence for good depended 
upon this effect, but the experiments of Seppilli contradict this belief, 
for he found that if atropine was given to an animal the surface of the 
cortex cerebri responded more readily than is normal to electrical 
stimulation. At one time it was held that belladonna acted on the 
spinal cord and peripheral nerves under such circumstances, but it 
should be remembered that we now know that atropine is only of value 
in relaxing spasm when given in full dose, oftentimes hypodermically, 
and that Albertoni has made a series of experiments to determine 
whether it irritates the motor centres of the cortex. In his hands 
repeated small doses or one large dose in no way retarded the con- 
vulsions commonly produced by stimulation of the brain. Both these 
investigators are therefore in accord. Under these circumstances 
it affects rather the motor nerve-endings than the central nervous 
apparatus. 



766 DISEASES. 

Nitrate of silver was brought into use long before the value of more 
recent drugs was known. Every one is agreed that it is without 
power for good. As the drug is eliminated very slowly, it rapidly 
accumulates in the body, and argyria soon comes on. It may be used, 
after all else fails, in doses of -J- to \ grain (0.01-0.15) thrice a day after 
meals, the mucous membrane of the inside of the lips and the con- 
junctiva being carefully watched for the early signs of chronic silver- 
poisoning. We certainly have no knowledge as to its influence on the 
nervous system; and if it acts at all, it must be by some alterative 
influence rather than by any other means. 

Nitroglycerin is to be employed in the treatment of petit mal, rather 
than haut mal, in the dose of 1 minim (0.06) of a 1 per cent, solution, 
once, twice, or three times a day. Our knowledge of its effects, so 
far as its curative influences are concerned, is very slight, but it seems 
to benefit some cases. Its action is fleeting, and it influences the 
brain but slightly, except it be taken just before an attack is expected 
or when the cardiac action is defective. 

The use of the nitrite of amyl is not for the purpose of directly 
curing the disease, but of warding off impending attacks, the warning 
of which is given by an aura of slow progression. It increases the 
severity of petit mal, but in epileptics who have a prolonged aura 
nitrite-of-amyl pearls, which are small glass beads containing a few 
drops of the drug, may be used. As the aura comes on the patient 
should break one of these in a handkerchief and inhale the drug, 
thereby putting aside the attack, The influence which the drug exerts 
upon the brain is secondary rather than primary ; and is probably 
dependent on its action on the blood or circulation. Its influence on 
the spinal cord and nerves is much more marked and direct, and it 
is most certainly a very powerful spinal depressant. Nitrite of amyl 
puts aside an attack by a sudden shock to the nerve-centres, which 
diverts them, so to speak, from their intended discharge, very much 
as a ligature around the arm stops an aura. When we remember 
that the drug acts instantly and converts much of the oxygenating 
blood of the body into a non-oxygen-carrying fluid by reason of the 
methsemoglobin produced, the sudden change in the cerebral nutrition 
and state is easily understood. 

In the treatment of the " status epilepticus" nitrite of amyl is of 
great value in checking the seizures, and may be used under these 
circumstances in heroic amounts, applied to the nostrils at intervals. 
During the presence of the tonic spasm, if it be severe enough to 
suspend respiration, it should be remembered that if the drug is not 
inhaled it is worthless. It is only when respiration is being carried 
on that it can enter the lungs and do its work. The nitrite of potas- 
sium or of sodium or nitroglycerin should be used internally to sup- 
plement the nitrite of amyl. Another valued method in treating 
the status epilepticus is free bloodletting. 

The use of anaesthetics during an attack of epilepsy is virtually 



EPILEPSY. 767 

useless, and in some cases dangerous, for ether is too slow in its effects, 
and may, by its irritant vapors, increase the tendency to laryngeal 
spasm or cause lung complications. Further than this, if uraemia is 
the cause of the fit — and this fact is unknown in every case when it 
is seen for the first time until the individual is carefully examined — 
the ether may further irritate the kidneys. 

Chloroform, though it acts much more rapidly, may cause sudden 
cardiac failure, and both drugs may increase the post-convulsive coma 
very greatly. In status epilepticus they may be used, as in such ca c/? 
the convulsions must be stopped at all hazards, but the preference 
should be always for amyl nitrite, which may be given hypodermically. 

The iodide of potassium is useless in epilepsy unless the disease 
is due to syphilis, when it is of the greatest service. Indeed, the 
bromide and all other drugs should be discarded while this one is 
pushed to the utmost. As is well known, syphilitics usually bear 
the drug extremely well, and the author knows of one instance in which 
no less than 800 grains (53.0) were taken every twenty-four hours, 
with rapid improvement as a result. This point is strongly insisted 
upon by all therapeutists and syphilographers, notably Fournier. 

Where the convulsions are due to the presence of a gumma, how- 
ever, the iodide of potassium is too slow in its action, and should be 
associated with mercury in order to break down the growth without 
delay, lest a seizure cause death by glottic closure, producing asphyxia 
or some similar accident. 

Chloral possesses the disadvantages, as compared with the bromides, 
of being a very fatal poison, which is an important fact to be borne 
in mind by the physician when giving it to a patient whose mind is 
already weakened by the disease or who is naturally stupid, and who 
may forget the dose and take too much. Its physiological action indi- 
cates much more fully that it may be of value than does that of many 
other more lauded remedies, since it exerts its chief influence on the 
motor pathways of the spinal cord and quiets the intellectual portion of 
the cerebral cortex, and so produces sleep. Seppilli has proved this 
by direct experimentation after the method employed by Albertoni. 
Its use, combined with one of the bromides, is often followed by the 
most desirable results, and it should be tried at all times unless some 
cardiac complication forbids it. It may disorder the stomach, and 
should, like the bromides, always be given well diluted and after meals. 

Of the more recent remedies, acetanilide stands in the foremost rank, 
and bids fair in some instances to rival the bromides. German-See, 
the author, and some others have reported cases which obtained 
marked relief from it, and more recent investigators have done like- 
wise. The drug will be found to exert its beneficial effect chiefly in 
chronic epilepsy. 

Antipyrine has been recommended by Lemoine in certain forms of 
epilepsy, but it has been condemned by other clinicians. He found 
it very useful in cases associated with migraine. In these cases the 



768 . DISEASES. 

results were better than with the bromides, but in the idiopathic 
simple varieties it was useless. Mairet and Combemale have used 
the drug in epileptiform mania with satisfactory results. 

In the epilepsy of childhood Solanum Carolinense in the form of 
the fluidextract, in the dose of 2 to 15 minims (0.1-1.0 mil.), is some- 
times a useful drug. 

The value of the treatment of epilepsy by borax has not received 
very wide recognition. Perhaps the most thorough studies of its effects 
have been those of Gowers in England and Folsom in America. It 
would seem that some cases which are obstinate under ordinary treat- 
ment are benefited by borax, but it is certainly not to be commonly 
employed. The dose generally given is about 15 grains (1.0). (See 
Borax.) 

In children who have single convulsive attacks the presence of 
worms should always be looked for, and when found they should 
be expelled as rapidly as possible. If they are oxyuris vermicularis 
(seat- worms), the best remedy by far is the injection of an infusion of 
quassia of such a strength that there are 2 ounces (60.0) of quassia 
in each pint (480 mils.) of water. 

In girls, where the removal of the worms from the rectum is not 
followed by relief, a careful examination of the vagina should be 
made, and quassia employed in somewhat weaker solution, as very 
commonly intense inflammation is there present, produced by migra- 
tion of rectal parasites. If the quassia is unobtainable in any case, a 
saturated solution of chloride of sodium may be employed. 

A very important point, which is constantly brought before the 
physician who is treating epilepsy, is that of diet. Nearly every 
patient who suffers from this disease inquires what he shall eat. Few 
researches of a thorough character have been carried out on a large 
scale to determine what may or may not be ingested. Curiously 
enough, the influence of diet in one research covering a number of 
cases of chronic epilepsy seemed to be of little moment. Thus, 
Merson examined 24 such cases, putting 12 of them on a purely 
vegetable, and 12 on a purely nitrogenous, diet. The result, after this 
study had been continued for two months, was that the vegetarians 
had had a few less fits than the others, but the difference was so slight 
as to be of almost no weight in determining the question. The view 
that meats in moderate amounts are harmful is erroneous. 

EPISCLERITIS. 

Episcleritis occurs in the form of reddish, sometimes violaceous, 
subconjunctival swellings, nodes or patches, which usually appear in 
the ciliary region on the temporal side, though they may develop in 
any portion of the zone. To severe types of this disease, in the form 
of diffuse, bluish-red injection, often associated with crescentic areas 
of infiltration in the cornea and involvement of the iris and ciliary 



EPISTAXIS. 769 

body, the term scleritis is applied. These lesions appear to be due 
to gout, tuberculosis, menstrual derangements, enterogenous auto- 
intoxication and focal infections in the buccal mucous membrane, 
sinuses and. tonsils; rarely syphilis. Hence the treatment requires 
ample general and local examination in order to discover and eliminate 
the cause. Internally the salicylates, aspirin and sometimes mercury 
and the iodides are useful, the medicinal and dietetic treatment being 
determined by the etiologic factor. Locally, atropine mydriasis is 
important, especially in the severe types, and hot compresses and 
dionin (5 per cent.) to relieve pain. Occasionally, eserine sulphate and 
pilocarpine chloride (J-J grain (0.0162-0.324 gm.) to the ounce (30 c.c.) 
are required, if iritis is not a complicating feature and there is a 
tendency to rise of intraocular pressure. In the presence of a tuber- 
culous taint injections of tuberculin are of service. In chronic types 
massage with the yellow oxide of mercury ointment (gr. j-5j) is indi- 
cated and scarification or cauterization of the nodes have been 
recommended. Subconjunctival injections of physiologic salt solution 
are occasionally useful. 

Episcleritis and scleritis are prone to relapse and the danger of 
involvement of the cornea and uveal tract is always present; hence the 
need of thorough study of all conditions, local and general. 

EPISTAXIS. 

Nose-bleed depends upon many causes, the chief of which are 
traumatisms, plethora, and the presence of ulcerations in the nasal 
chambers. It also occurs as one of the prodromata of typhoid fever 
and in some cases of cardiac valvular disease. 

The measures to be adopted for its control are both medicinal and 
non-medicinal. If the individual is full-blooded and strong, full 
doses of tincture of aconite or veratrum are useful, say 5 to 10 minims 
(0.30-0.60) of one of them, followed in a half-hour by a smaller dose, 
if necessary. The value of these drugs depends upon their power of 
lowering blood-pressure, and in consequence decreasing the leakage 
from the break in the wall of the bloodvessel. Some physicians have 
recommended ipecac in full nauseating doses to relax the arterial 
system. Sometimes, when the oozing is slow, turpentine, oil of erigeron, 
or hamamelis, taken internally, does good. In the way of local treat- 
ment by far the best application, because it is efficacious and yet harm- 
less, is adrenalin chloride in salt solution 1 : 1000, which should be 
placed in the nasal chambers on a piece of cotton, or compound tinc- 
ture of benzoin may be used in a similar manner pressed against the 
septum. If this does not control the hemorrhage, an atomized spray 
of Monsel's solution, in the strength of 5 minims to the ounce (0.3-30.0) 
of water, may be of service. (See Coagulose). 

The non-medicinal measures to be employed if the bleeding is 
severe consist in plugging the anterior nares with pledgets of cotton or 
49 



770 DISEASES. 

pieces of lint soaked in adrenalin solution or weak vinegar. If this does 
not control the hemorrhage, the posterior nares may also be closed 
by plugs, and compression of the facial artery of the same side as the 
bleeding nostril be made upon the superior maxilla near the nose, 
thus decreasing the blood-supply. The head must be kept raised, and 
the patient must not bend over a basin or wear a tight collar. 

A piece of bacon fat cut to fit and placed in the nostril may stop 
epistaxis which has resisted other measures. 

As a household remedy diluted vinegar may be injected into the 
nostrils, or lemon-juice may be employed in the same way. 

Sometimes, if the patient raises one or both hands high above the 
head, the hemorrhage ceases. This is due to the fact that the easiest 
pathway for most of the blood is straight up the brachial arteries 
rather than through the tortuous vessels of the face. A hot foot-bath, 
by dilating the veins of the lower extremities, draws away the blood 
from the face and is a useful measure; but if bleeding has been profuse, 
this may cause the patient to faint unless he lies down when his feet 
are in the water. In other cases a hot-water bag applied over the 
dorsal vertebra? is efficacious, and sometimes cold when so used is of 
service. A piece of ice pressed against the nose may prevent further 
hemorrhage by causing localized anaemia. 

Where the nasal hemorrhage results from traumatism with fracture 
of the bones, and great loss of blood ensues, compression of the bleeding 
vessel or its supplying vessel should be made if possible. 



ERYSIPELAS. 

This disease is now generally recognized as dependent for its exist- 
ence upon a germ. The streptococcus of erysipelas is practically 
identical with that of pus, and the disease is at first a distinctly local 
one. The changes which have taken place in its treatment are chiefly 
the local measures, while those methods which have been used internally 
for many years have undergone no alteration. 

In a large proportion of cases erysipelas develops because the vital 
resistance of the patient has been lowered by some acute illness or by 
a chronic malady like nephritis or diabetes. For this reason its spread 
in the skin and the toxaemia it causes must be controlled by the em- 
ployment of every measure that will enable the patient to combat 
the infection. Rest in bed is essential and supporting treatment 
is demanded. J. M. Da Costa recommended, and others have car- 
ried out with success, the practice of using pilocarpine in sweating 
dose (-§- to ■§• grain) hypodermically in these early stages. (See Pilo- 
carpus.) It is to be remembered that this use of pilocarpine is not to 
be resorted to if debility exists. I never use it. 

The internal treatment of erysipelas par excellence is the plentiful 
use of the tincture of the chloride of iron — 20 to 30 minims ( 1.3-2.0), 



EXHAUSTION AND DEPRESSION. Ill 

or even 40 minims (2.6), well diluted, four times a day. The diet 
should be regulated and the bowels kept in good order." Any exces- 
sive febrile movement is to be treated by the use of cool sponging 
with friction. If the patient passes into a typhoid state supportive 
measures must be used and alcoholic stimulants added to the food, 
which should be predigested or prepared so as to be readily absorbed. 

During convalescence the use of tonics, both in the form of iron 
and of bitters, is particularly indicated if recovery of strength is slow. 

The local treatment of erysipelas is very various, but in the majority 
of cases resort need be had to but one method. By far the best dress- 
ing for the majority of cases of erysipelas is a modification of that 
of vonNussbaum, which the author has tried in a great number 
of instances with success. The skin of the part involved is care- 
fully cleansed with Castile soap of the purest form, and then it is 
washed off with a 1 : 1000 solution of bichloride of mercury. The 
skin is dried with a soft towel, and a thick coating of ichthyol with 
lanolin applied, the strength of this ointment being half and half. 
Over this is placed antiseptic gauze or sterilized absorbent cotton, 
and adhesive strips or a bandage is used to keep the dressing in place. 
Sometimes the ointment alone may be applied if the area is small. 
Under this treatment the results are often extraordinary in all stages 
of the malady. Where ichthyol is not obtainable, a thick coat of white- 
lead paint, as it is sold in cans before it is mixed with any thinning 
substance, will be found of service in an emergency. 

The iron and ichthyol method is that always followed by the 
author. (See Magnesium Sulphite.) 

The plan recommended by Higginbottom, of applying nitrate of 
silver, is sometimes successful. It consists in the use of a solution 
of the strength of 80 grains to 4 drachms (5.3-16.0) of distilled water, 
which is thoroughly applied with a camel' s-hair brush over the entire 
inflamed area and for a little space beyond. The application must be 
made twice or thrice to secure a good coating. This treatment will 
often arrest the inflammation and prevent its spread, but has caused 
sloughing; the author has never used it. 

EXHAUSTION AND DEPRESSION. 

While the treatment of both these conditions is almost identical in 
some respects, it is nevertheless important that a clear idea of the 
difference between the two be clearly understood, if for no other 
reason than that the physician may recognize that exhaustion is a 
far more serious state than depression. It also requires more careful 
treatment. The man who is depressed retains in his body all the 
vital forces necessary for the maintenance of life, but they are tem- 
porarily in abeyance from some cause. As soon as the incubus is 
taken away the system at once asserts itself and recovery takes place. 
This is not the case with a man suffering from exhaustion. In this 



772 DISEASES. 

patient his strength is sapped and lost. The man depressed is the 
giant lying unconscious from a blow on the head; the man exhausted 
is the same giant after a long attack of typhoid or other fever of a 
similar nature. The treatment of depression is stimulation; of exhaus- 
tion, not only stimulation, but rest, feeding, and protection from ex- 
posure. 

EYE-STRAIN. 

Eye-strain, in the broadest acceptation of the term, is the name 
applied to those symptoms which may be caused by the presence ot 
refractive error, or imbalance of the ocular muscles. While all varie- 
ties of ametropia may cause eye-strain, hypermetropia and astigmatism 
are most potent in this respect. Fully 75 per cent, of functional head- 
aches are caused by refractive errors; and these headaches may vary 
from a moderate frontal distress to violent explosions of pain, and may 
be situated in any portion of the cranium. Moreover, they may be 
entirely unassociated with any pain in the eyes or any apparent dis- 
turbance of vision, and are frequently caused by low degrees of refrac- 
tive error; in fact, they are perhaps more frequently caused by them 
than by the higher defects. In addition to headache, eye-strain may 
cause pain in the back, especially between the shoulder-blades and at 
the root of the neck, precordial pain, vertigo, drowsiness, insomnia, 
habit-chorea, choreiform movements, convulsive seizures, melancholia, 
neurasthenia, palpitation of the heart, syncope, night-terrors, stomachic 
disturbances, constipation, flatulent dyspepsia, and a variety of gen- 
eral or so-called reflex neuroses. The existence of any of these symp- 
toms or affections should direct the attention of the attending physician 
to the condition of the eyes, and refractive error and muscular im- 
balance should be corrected. Certain cases of so-called spinal curva- 
ture, head tilting, head nodding, and torticollis, in young persons are 
due to the influence of ametropia and impaired muscle balance. 

FEET SWOLLEN, TENDER, OR SWEATING. 

These comparatively simple yet annoying conditions are often 
brought before the physician for relief, and patients suffering from 
them will frequently be more grateful for skilful treatment than in 
the event of recovery from a severe illnes.s. 

Swelling of the feet occurs chiefly in two classes of cases, excepting, 
of course, dropsy. The two classes named are old persons taking too 
little or too much exercise, and who may have gouty or rheumatic tend- 
encies, and those who by constant standing or walking cause congestion 
of the lower extremities, chiefly by fatigue, or by wearing ill-fitting 
shoes, or by running over- uneven ground, causing bruising. Where 
the swelling takes place in the first class, small doses of arsenic trioxide, 
To to to" g ram (0.001-0.0015), often do good, and careful examination 



FEVER, AND ITS TREATMENT. 773 

should be made of the circulatory, renal, and respiratory apparatus 
to discover any weak points, such as vascular relaxation or tendencies 
to varicosities. The distilled or fluidextract of hamamelis is often of 
service in the dose of % to 1 drachm (2.0-4.0) of the former and 10 to 
20 minims (0.60-1.3) of the latter preparation. In some cases absolute 
rest of the feet will be necessary before a cure is reached. 

Where the feet are tender a common cause is bruising from too 
thin soles on the shoes, too tight shoes, and from abrasions or skin 
disease. More commonly than all they become sore from excessive 
sweating and resulting maceration. In some instances the pain is 
due to a broken-down instep. The pain is often treated as rheu- 
matism. 

The treatment of sweating and tender feet is, of course, the removal 
of the cause and the use of remedies designed to toughen and harden 
the skin of the parts. Probably the best application for this purpose 
is a solution of salicylic acid and borax, half and half, in water and 
glycerin, rubbed over the feet night and morning. If the sweating is 
very profuse, clean stockings should be worn each day, the stockings 
being previously soaked in a strong solution of borax and dried. The 
following prescription affords a useful powder: 

1$ — Pulveris acidi salicylici . . . . . gr. xx vel xl (1.3-2.60). 

Pulveris acidi borici 5ij (8.0). 

Pulveris amyli q. s. ad 5j (30.0). — M. 

S. — To be dusted over the feet night and morning, after washing and thor- 
oughly drying them. 

One of the most efficient applications is a solution of formaldehyde 
of such strength that 1 part of the commercial 37 per cent, solution 
\s mixed with 4 parts of water. Even this may be too strong in some 
cases. A more agreeable application is diluted Euformol. 

Sometimes the use of cotton instead of woollen stockings may aid 
in the cure. 

FEVER, AND ITS TREATMENT. 

(For the Treatment of each Fever, see its Title.) 

At the present time the medical profession is universally of the 
opinion that fever is a disorder of calorification dependent upon 
nervous action, said nervous action being the result of various causes, 
such as the presence of poisonous materials in the blood causing per- 
verted functional activity of the heat centres. The rule of practice 
should be to control all fevers that need control by the use of cold 
sponging or bathing and to resort to antipyretic drugs as little as 
possible. 

Antipyretics may be divided into three great classes: first, the sub- 
stances which allay or prevent fever by inhibiting its production; 
second, the drugs which possess the power of decreasing bodily tem- 



774 DISEASES. 

perature by increasing the dissipation and decreasing the production 
of heat; and third, the compounds which allay fever, not by stopping 
the development of heat-units, but by so increasing the dissipation 
of heat that the loss is greater than the production. The first and last 
of these classes are directly opposed to one another. The second class 
is half-way between, and it is to this class that most of our antipyretic 
drugs belong. 

The objection to the use of all antipyretic drugs is that they depress 
the patient and decrease his power of resisting disease. 

The presence of a high temperature alone does not constitute the 
sole indication for treatment. The physician should be governed by 
the state of the patient who is laboring under the malady. A temper- 
ature of 106° F. in a young healthy man suffering from an attack of 
some disease of short duration does not mean very great danger, but 
a temperature of 103° F. day in and day out in typhoid fever does 
mean danger, chiefly because it is a gauge of the toxsemia, and must 
be carefully attended to. The question is one not of actual degrees of 
Fahrenheit, but rather as to whether the state of the patient is toxic. 

We have only two measures for the relief of fever which are reliable. 
These are the employment of antipyretic drugs and the use of cold 
water. As already stated, drugs are to be used very rarely, but the 
beneficent effects of the use of cold water are extraordinary, and it 
should be freely employed if the fever is high. (For the mode of 
using acetanilide and antipyrine see pp. 66 and 106, and for the use 
of cold see p. 563.) 

The friends of the patient, if they are intelligent, can easily be 
taught how to use cold sponging with friction, and good results, far 
superior to those produced by antipyretic drugs, are thus obtained. 
The reasons for this are discussed farther on. The water should be 
as cold as is necessary to reduce the fever satisfactorily in twenty 
minutes of sponging, and reaction must be produced by friction applied 
to the skin. This reaction is more important than the reduction of 
the fever. (See Cold in Fevers, Part III.) 

(For the use of guaiacol externally in fever, see article on Guaiacol.) 



Sthenic Fevers. 

The application of antipyretic drugs to the febrile temperatures 
occurring in sthenic cases is not so irrational as their employment in 
a prolonged low fever of the adynamic type, but the wise physician 
will always endeavor to avoid their use if possible. Fever is not, as a 
rule, a very harmful process unless it is continued for a long period 
or is exceptionally high. Indeed it may even be beneficial. Anti- 
pyretic drugs decrease oxidation, probably interfere with ordinary pro- 
tective natural efforts against disease, and place upon the eliminating 
organs the task of excretion. In acute illnesses, if the use of cold is 



FRECKLES AND CHLOASMA. 775 

impossible, these remedies may be given, but usually it is unnecessary 
to employ them, for unless the fever is long continued it is not harmful 
in itself. In scarlet fever the use of such drugs should be avoided, 
because the kidneys are in danger. 

If in any case it is decided to give antipyretic drugs, they should 
never be pushed to the point at which even moderate cyanosis develops; 
and if they do not control the fever in moderate dose, they should be 
discarded and cold bathing insisted upon. The use of antipyretic 
drugs and cold sponging simultaneously is absolutely harmful. 

Personally the writer never under any circumstances employs anti- 
pyretic drugs for the reduction of fever. 

In thermic fever, or sunstroke, the employment of antipyretics is 
often useless. The excessively rapid upward rise of the temperature 
responds in no way to drugs, and there are many cases on record in 
which the use of antipyrine has utterly failed of good result. 



Asthenic Fevers. 

(Fevers of a Typhoid Type.) 

In the opinion of the author antipyretics should not be employed 
in the reduction of the pyrexia of the typhoid state, our main reliance 
being upon cold applications. They ought never to be combined with 
the cold bath, as they prevent the one thing we seek in the use of the 
cold, namely, reaction. Aside from the fact that the author has found 
such an opinion well founded in a large number of cases, logical reason- 
ing endorses its correctness. Even if antipyretics were perfectly 
innocuous, their constant use in fever would but give the already 
overstrained kidneys the task of their excretion, while the stomach, 
already disturbed by necessary medicines and illness, has enough 
to do without the addition of another load. Further than this, we 
know that these drugs are not perfectly harmless, and we also know 
that they decrease oxidation, which is not the case with the cold bath, 
which increases it. The writer reiterates that in typhoid and other low 
fevers of the continued type antipyretics should not be given. (For 
Brand's treatment, see Cold, Part III.) Fever will sometimes resist 
all doses of antipyretics we can give or all that it is safe to give, but no 
fever can completely resist the cold sponge when properly used, for by 
its use we produce beneficial results by reaction even if an actual fall of 
temperature does not take place. In septic fever and in tuberculosis 
antipyretics are harmful owing to the depression and the increased 
sweating which is apt to be produced. 

FRECKLES AND CHLOASMA. 

The removal of freckles is readily accomplished, but their return is 
inevitable if any exposure to the sun or wind occurs. One of the best 



776 DISEASES. 

applications for their removal is a solution of corrosive sublimate, in 
water, varying in strength from 1 to 4 grains to the ounce (0.06-0.25: 
30.0), and applied night and morning until the skin shows that it 
is irritated, when the lotion must be stopped for some days, after 
which its use may be begun again. A very efficient and much less 
poisonous remedy to leave about the room is a saturated solution of 
boric acid in water, applied in the same manner as is the solution 
of bichloride of mercury. 

Another remedy is lactic acid, 10 grains to a drachm (0.60:4.0) of 
water, used in the same manner as the solution of the bichloride of 
mercury. The following prescription is recommended by Unna: 

1$ — Bismuthi oxidi, 

Pulveris amvli aa gr. xxx (2.0). 

Kaolini 5j (4.0). 

Glycerini f 5ij (8.0). 

Aquse rosae q. s. ad f oij (60.0). — M. 

S.^Paint on spots and allow to dry, washing the drug off before each new 
application. 

Or the following may be used: 



1$ — Zinci oxidi ... 
Hydrargyri ammoniati. 
Olei theobromatis . 
Olei ricini .... 
Essentise rosae . 
S. — Apply night and morning. 



gr. iij (0.2). 

gr. iss (0.08). 
f5iiss(10.0). 
f 5iiss (10.0). 

gtt. x (0.60).— M. 



GASTRIC CATARRH (ACUTE). 

By far the most important point in the treatment of acute gastric 
catarrh is the regulation of the diet. The dietetics may be divided 
into two parts — first, the regulation of the food during convalescence 
or during the attack; and, secondly, the character of the food to be 
used during the interval following one attack and preceding the next. 
Total abstinence from food in the acute stages of the attack, and 
absolute bodily and mental quietude, are advisable. There are 
several reasons for this. In the first place, the juices of the stomach 
are in an abnormal state and unfit to act properly if the stomach 
receives more food. Secondly, the mucous membrane of the stomach 
is already hyperaemic from the inflammation, and, as the normal 
viscus becomes physiologically hypersemic on the ingestion of food, we 
would add to the congestion of the bloodvessels did we allow more 
nourishment to enter the stomach. Last of all, the excess of the 
mucus and lactic and. butyric acids present renders any new food 
impure before it can be assimilated, and so prolongs the trouble. 
As the attack passes off small amounts of food may be given, which 
should be of a kind readily digested and not likely to become easily 
decomposed or rendered acrid. Milk with a large percentage of lime- 
water or citrate of sodium is to be used to prevent a too firm coagulation 
and to decrease the secretion and acid reaction of the mucus. The 



GASTRIC CATARRH. Ill 

thirst is often excessive, although anorexia is complete, and small 
pieces of ice may be administered for its relief. Small doses of bismuth 
subnitrate (grains 2 [0.12]) and of cerium oxalate (grain 1 [0.06]) every 
two hours are advisable. 

Commonly it will be found that the patient rapidly improves up to 
a certain point, then stops improving or relapses. This is sometimes 
due to an accumulation of mucus, which when mixed with food causes 
it to undergo fermentation. If marked evidences of the presence 
of this secretion are given, a mild and gently acting purge, such as 
calcined magnesia, followed by a little orange juice, may be employed 
to dislodge the fermenting mass. In other instances the relapses 
depend upon a tendency to a condition of atony, which can only be 
overcome by prolonged and careful treatment adapted to the im- 
provement of the general health. Sodium bicarbonate with com- 
pound infusion, or compound tincture, of gentian may be used during 
convalescence, and small sips of effervescing draughts are useful. If 
constipation exists and vomiting forbids the use of the ordinary purga- 
tives, a Seidlitz powder divided into fourths or fifths, and taken in 
this way every fifteen minutes or half-hour, will settle the stomach, 
move the bowels, and often carry away mucus. 

If there is much epigastric distress, a spice or mustard poultice 
is often of service. 

Sweets and starches are to be rigidly denied the patient. If ansemia 
exists, iron may be used, but this is rarely needed. 

The abdomen should be carefully protected with flannel, and 
draughts and unsanitary surroundings avoided. 



GASTRIC CATARRH (CHRONIC). 

Chronic gastric catarrh is a condition of the stomach commonly seen 
in a more or less well-developed form. It is often associated with 
much indigestion and the eructation of sour liquids, or even with 
active vomiting. The secretions of the stomach are nearly always 
abnormal, and fermentative changes are constantly present in the 
gastric contents. Lavage is almost always to be resorted to for its 
relief. (See Lavage, Part III.) 

By far the best treatment for this condition is the use of counter- 
irritation over the epigastrium by means of tincture of iodine, the strict 
regulation of the diet, and the use, internally, of nitrate of silver and 
extract of hyoscyamus, and, if great hyperacidity exists, the admin- 
istration of the subnitrate of bismuth. Often, however, the better 
remedy is bicarbonate of sodium in the dose of 5 to 20 grains (0.3- 
1.3). In many instances the patient will be greatly benefited by the 
use of a Seidlitz powder or Carlsbad salt 1 or Abilena or Hunyadi or 

1 Artificial Carlsbad salt may be ordered, composed of 8 ounces of sodium sulphate, 
^ ounce of sodium chloride, and 1 ounce of sodium carbonate. The dose varies from 2 
drachms to \ ounce (8.0-16.0). 



778 DISEASES. 

Apenta water before breakfast each morning, as this washes out 
the stomach, dissolves the mucus, and unloads the mucous membrane 
of its congestion, at the same time overcoming any engorgement of 
the liver. The efficiency of these purgatives may be increased by 
following them with a draught of hot water. Constipation is nearly 
always present, and should be relieved by appropriate drugs such as 
the waters just named or cascara sagrada, of which the best prepara- 
tion is the aromatic fluidextract, rendered free from bitter taste, as 
in "cascara aromatic." 

All fats, rich foods, strong meats, ham, bacon, and fried foods are 
to be avoided, and only light broths, koumyss, or matzoon resorted 
to if the case be an obstinate or severe one. A nitrate-of-silver pill 
should be used half an hour before each meal, and be prescribed as 
follows: 

1} — Argenti nitratis gr. iv (0.25). 

Extracti hyoscyami gr. x (0.60) . — M. 

Fiant piluloe No. xx. 

S. — One pill half to one hour before each meal. 

In cases in which the chronic inflammatory process has gone on to 
atrophy of the tubules the use of hydrochloric acid is often of great 
value. (For formula, see Hydrochloric Acid.) 



GASTRIC DILATATION. 

Gastric dilatation is to be treated with two objects in view, namely, 
the relief of the symptoms and the correction of the gastric condition 
as far as possible. The relief of the symptoms depends upon the suit- 
able regulation of the diet, the proper use of washing out the stomach 
(lavage), and the use of other remedial measures. All these efforts 
also tend to relieve or modify the underlying gastric state in that 
they remove certain influences which, if continued, would necessarily 
make the condition of the patient worse. The actual state of dilatation 
when once developed cannot be materially improved. In the way of 
diet, all articles bulky in character, such as cabbage, and those foods 
which are slow of digestion and capable of rapid fermentation should 
be excluded. Particularly is this true of rich or fatty foods, and of 
drinks such as beer and ale. When food is given, it is to be admin- 
istered in small amounts and often, rather than in large, full meals, and 
it should consist chiefly of roasted and broiled meats, easily digested 
starches, such as "Zweibach" bread or "pulled bread," and the 
green vegetables, like lettuce, asparagus, string beans, and moderate 
amounts of spinach. To aid in the digestion of vegetable foods 2 to 
4 grains (0.12-0.25) of taka-diastase should be taken with each meal, 
and to this may be added a little powdered capsicum to stimulate the 
stomach. Where gastric digestion is very faulty, predigested food 
and rectal alimentation should be employed for a time. In the way 



GASTRIC AND DUODENAL ULCER. 779 

of direct treatment, the stomach of the patient should be washed out 
with the stomach-tube at least once a day; and if fermentation is 
active and food is apt to be retained in this organ, it should be thor- 
oughly cleansed before each meal, and some mild antiseptic, like 
boric acid, used in the washing fluid. Lavage not only removes 
decomposing food and mucus, but also exercises a beneficial effect on 
the gastric walls. The water used should not be cold nor tepid, but 
hot, and may contain 1 drachm (4.0) of boric acid to the pint (480 mils.). 
Faradic electricity applied to the epigastrium or to the stomach direct 
by a swallowed electrode is useful. In the way of direct treatment 
by drugs, the physician should use full doses of dilute hydrochloric 
acid to aid digestion, say, 20 to 30 minims (1.3-2.0), and give strychnine 
in full doses to aid this function, and also to increase the motor power 
of the stomach, so that it will urge the food on into the bowel. Often 
the lavage, electricity, and strychnine combined will produce great 
improvement. General hydrotherapy in the form of cold douches 
to the entire body, and exercise on horseback or on foot, are valuable 
in many cases. If fermentation is marked, antiseptic substances, like 
beta-naphtol, may be employed internally. As the majority of cases 
are due to some obstructive lesion at the pylorus this possibility 
should be investigated and, if present, surgical relief sought. 



GAS1 : RIC AND DUODENAL ULCER. 

In the treatment of gastric ulcer three points must be borne in 
mind as being essential. These are, rest for the stomach as far as 
possible, rest for the patient, and the maintenance of the general 
health. The first of these points involves a consideration of diet. 
If in any case the stomach is very irritable, it is best to place the 
patient in bed and nourish her for from two to eight days by means of 
enemata. Probably the best form of nourishment for this purpose is 
a mixture recommended by Dreschfeld, and consisting of 2 raw eggs 
with 2 ounces (60.0) of beef-tea and a little brandy, which may amount 
to 1 ounce (30.0) if the patient really needs stimulants. It may be 
well to place a little pancreatin in this injection to peptonize the pro- 
teids, but if this is done the alcohol must be left out, as it will inter- 
fere with the activity of the pancreatin. Ewald, of Berlin, suggests 
the following nutrient enema: Beat up 2 eggs with a tablespoonful 
of cold water; to this" add a little starch boiled in half a cupful of a 
20 per cent, solution of grape-sugar, and a wineglassful of red wine. 
The solution is to be well mixed at a temperature not high enough to 
coagulate the albumin, and injected as high up into the bowel as 
possible. For the relief of thirst, which may be excessive if rectal 
alimentation is resorted to, the patient may hold in the mouth small 
pieces of ice or drink moderate quantities of cool barley- or rice-water; 
but much thirst can be prevented by resorting to hypodermoclysis, 



780 DISEASES. 

whereby the body is supplied with plenty of fluid. (See Part III.) 
After this treatment has been used for some days, small quantities of 
food may be given by the mouth, such as a little peptonized milk or a 
little warm milk with lime-water in the proportion of half and half, or 
one part of lime-water to two of milk. After this, thin arrow-root or 
gruel may be given in moderate quantity, with taka-diastase to aid its 
digestion. It is better to give the food in small amounts every two hours 
than in larger quantity three times a day. 

The increase in rations, both as to variety and amount, should be 
most gradual, the physician extending the dieting over at least six 
weeks, of which the first two had best be spent in bed. It is well to 
use massage and electricity under these circumstances to preserve nutri- 
tion, as in the rest cure. (See Rest Cure.) Beef-tea and soups had 
better be avoided during the early stages of the treatment, as they will 
irritate the stomach. Soft-boiled eggs, tender chicken or game, and 
minced lamb may be finally given. Cheese, coffee, tea, beer, and 
ale are to be avoided, as are all very hot drinks. Fresh green vege- 
tables may be used in moderation, but fresh bread and unripe fruit 
must be carefully avoided. When milk is taken it should be 
warmed. The presence of gastric pain indicates that the diet must 
be cut down in quantity and the nutrition maintained solely by 
rectal injection. 

On the principle that healing of the ulcer will not take place in the 
presence of a condition of general malnutrition and acidity, Lenhartz 
has opposed the starvation method of treating gastric ulcer, and has 
advocated the use of small quantities of food to be given every hour, so 
that the nutrition may be improved without the stomach at any time 
being overburdened or distended. The stomach is given absolute rest 
between 7 p. m. and 7 a. m. Lenhartz's treatment consists in absolute 
rest in bed for a month and in feeding the patient with small quan- 
tities of beaten-up eggs and milk, the quantities being increased day 
by day. An ice-bag is kept constantly applied to the epigastrium, 
and after the* first week soft-boiled rice, minced meats, and semisolid 
and solid foods are gradually allowed. 

Another advantage which is claimed for this method is that the food 
takes up the free hydrochloric acid and so prevents it from acting 
upon the ulcer, and the well-known fact that taking of food often 
relieves the pain of gastric ulcer is advanced as an argument in sup- 
port of this view. The actual quantities of foods allowed by Len- 
hartz consist on the first day of from 7 to 10 ounces of milk with one 
egg, and the increase is 3J ounces of milk each day and one egg each 
day until a quart of milk and six to eight eggs are ingested. The 
amount of meat first given is 2 ounces. The bowels are not dis- 
turbed by treatment during the first week, but they are not prevented 
from moving naturally. If they do not move naturally an enema is 
given every fourth day during the rest of the treatment. Although 
the number of calories which the patient receives during the first few 



GASTRIC AND DUODENAL ULCER. 781 

days is considerably below the number actually required for the main- 
tenance of nutrition, the gradually increased quantities of food soon 
bring the calories up to about 3000 per day, which is fully as large as 
an individual in perfect health needs to ingest. He claims that the 
number of instances of hemorrhage are materially decreased by this 
method, as is also the percentage of relapses. This form of treatment, 
while advantageous in some cases, is not applicable in those instances 
in which the taking of food produces great pain, but it is the plan I 
commonly employ. 

The drug treatment of these cases is palliative as to pain, and 
curative. For the pain, counterirritation of a more or less severe and 
constant type should be applied to the epigastrium, either as a spice 
or mustard plaster or by means of a hot-water bag. The counter- 
irritation should be as continuous as possible. Sodium bicarbonate 
and the subnitrate or subcarbonate of bismuth are also of service in 
the dose of 20 grains (1.3) each, and to these may be added from 
2V to i grain (0.003-0.015) of morphine sulphate, J to \ grain (0.015- 
0.03) of dionin, or 1 grain (0.06) of codeine. These may be given thrice 
daily if necessary. Only the smallest dose of morphine necessary to 
relieve the pain should be employed. A valuable treatment for the 
pain and for the acidity is the following pill: 

1^ — Argenti nitratis . gr. iv (0.25). 

Extracti hyoscyami gr. x vel xx (0.60-1. 3). — M. 

Fiant x>ilulse No. xx. 

S. — One pill half to one hour before meals. 

Another useful drug in such cases is chloretone in 5-grain (0.30) 
doses, given in capsule three times a day half an hour before food. 
When great gastric acidity is present, which is not controlled by the 
pill named above or by the use of chloretone, the following formula may 
be employed: 

J£ — Sodii bicarbonatis, 

Magnesii oxidi ponderosi, 

Calcii carbonatis aa oj (30.0). 

Olei menthae piperita? rr\x (0.60). — M. 

S. — A saltspoonful every two hours in a little water. 

For the constipation which is frequently present the patient may 
receive a dose of Carlsbad salt or phosphate of sodium, or even the 
sulphate of magnesium before breakfast, although it is best, as a rule, 
to rely upon an enema each day to produce a movement. 

For the relief of vomiting and of hsematemesis absolute abstinence 
from food, so far as its administration by the mouth is concerned, is 
to be insisted upon for a period of several days. Nutrition must be 
maintained under such circumstances by feeding by the rectum with 
predigested food. (See Part III.) If the vomiting is persistent, small 
doses of cocaine, J grain (0.015), may be given, or cocaine and bismuth 
subnitrate combined. Sometimes drop doses of creosote are useful, or 
phenol may be given in the same dose with 20 grains (1.3) of subnitrate 



782 DISEASES. 

of bismuth. If there is hematemesis good results may follow the 
use of a drachm of the solution of adrenalin chloride, or of the solution 
of the subsulphate of iron (Monsel's solution) in the dose of 3 minims 
(0.20) in a little water every half-hour. Cold compresses or an ice-bag 
may also be applied to the epigastrium for the same purpose. 

Should perforation of the stomach occur, operative interference is to 
be promptly resorted to after the shock has been treated by supportive 
treatment in the way of heat to the limbs and the hypodermic use 
of ether, brandy, or atropine. Morphine should also be given freely 
unless collapse is too pronounced, as it tends to diminish abdominal 
pain and inflammation. 

In obstinate cases of ulcer with much pain and evidence of a severe 
lesion, a surgeon of experience should perform gastroenterostomy or 
gastrojejunostomy, to permit healing of the ulcer, particularly if there 
has been repeated hemorrhage. The decision as to whether a physician 
or a surgeon should take charge of a case of gastric ulcer may be 
determined on the following facts: 

When the symptoms are the ordinary ones of gastric distress and 
hyperchlorhydria the case is medical. If there are signs of pyloric 
obstruction, as represented by dilatation, or hour-glass contraction, 
adhesions, or repeated hemorrhage, the case is surgical, the more so 
if there is a long history of gastric trouble. The possibility of a 
chronic ulcer ultimately becoming malignant is also to be borne in 
mind when an operation is considered. 

Duodenal ulcer is to be treated medically or surgically, the latter 
method being used when the condition has lasted so long that healing 
is not likely to occur, when the pain is severe or the general health 
and comfort of the patient cannot be maintained by medical means. 
The occurrence of an intestinal hemorrhage severe enough to jeo- 
pardize life indicates operation to prevent recurrence, but not until 
the patient has rallied, and, in most instances, not until the corpuscu- 
lar and hemoglobin content of the blood are high enough to make 
surgery safe. Surgery is also indicated, if the hemoglobin is not below 
50 per cent., when the constant presence of occult blood in the stools 
shows that the ulcer is leaking this fluid. 

The medical treatment is as follows : The associated gastric hyper- 
acidity with pyloric spasm may be controlled by J drachm (2.0) of 
sodium bicarbonate dissolved in water half-way between meals. Milk 
of magnesia in J-ounce doses may be taken at bedtime or during the 
night to relieve distress. Mineral oil may be used to soothe and 
protect the ulcer and in overcoming intestinal stasis. If the acidity 
is very severe full doses of extract of hyoscyamus, as § grain (0.02), 
as it is more sedative than belladonna, may be given in pill. In some 
cases excellent results follow resort to duodenal feeding by the duo- 
denal tube. For associated anemia iron citrate may be given hypo- 
dermically, or cacodylate of sodium (which see). The diet should be 
that employed in the treatment of gastric ulcer. 



GASTRO-ENTERITIS. 783 ■ 

GASTRITIS (ACUTE). 

This is generally due to the ingestion of irritant foods or drinks 
rarely arising in its true acute form from other causes. 

The treatment is to be directed entirely to the prevention of the 
spread of the inflammation and to the relief of that already developed. 
If the patient is seen soon after the onset of the trouble, the stomach 
is to be emptied of all irritant substances by means of vomiting induced 
by large draughts of warm water, or, better still, by the use of the 
stomach-tube, as the retching may increase the irritation. Mucilaginous 
drinks are to be given freely, and albuminous materials seem especially 
useful. Oils and similar protective liquids aid in preventing further 
damage. Opium, to allay pain and the local and systemic irritation, 
is invaluable. This drug should always be given in liquid form, and 
the deodorized tincture is the best in this respect, owing to its freedom 
from narcotine. Paregoric contains too little opium to be of value. If 
the stomach will not retain drugs, they should be given by the rectum. 
If evidences of collapse appear, hot applications, atropine, or belladonna 
should be exhibited. It is important that the heat should be applied 
over the epigastrium and chest, and a flaxseed poultice is the best 
method of doing this. Practically, the same rules hold good in regard 
to diet in both acute gastritis and in gastro-enteritis. 



GASTRO-ENTERITIS. 

Gastro-enteritis is a condition of inflammation affecting the entire 
alimentary canal in some instances, and commonly produced by the 
ingestion of some irritant substance, either in the form of bad food, 
poisons, or mechanical irritants, such as grape-seeds or cherry-stones. 
The symptoms accompanying it are exceedingly various, but consist 
chiefly in pain of a griping character, with watery or mucous stools, 
or, if the inflammation be very severe, absolute and unyielding con- 
stipation may be present. The nervous symptoms depend upon the 
degree of irritation and the general nervous tendency of the patient ,- 
and if the trouble is very severe, a condition of shock or collapse 
may result. 

If the irritation is very intense, exfoliation of the mucous membrane 
may take place, the epithelium coming away in shreds. 

The treatment of gastro-enteritis depends upon its severity and 
cause. Almost always we first allay the pain and tendency to inflam- 
mation by the hypodermic use of morphine, and immediately follow 
this or precede it by an emetic of a non-irritating and rapidly acting 
type, such as apomorphine, provided there is reason to believe that 
the poison or food still remains in whole or in part in the stomach. If 
the irritant has been taken some time before the physician is called 
to see the case, emetics are contraindicated, as by disturbing the 
abdominal contents they increase the inflammation. If the irritant 



784 DISEASES. 

has passed the pylorus, castor oil, in the dose of 2 to 3 tablespoonfuls 
(30.0-45.0) to an adult, may be given to sweep out the offending mate- 
rials and lubricate the intestinal walls. The sulphate of magnesium is 
of value, because, in addition to its purgative effect, it also depletes the 
inflamed bowel. Having got rid of all offending materials, opium is 
to be freely used to allay irritation and control diarrhoea (see Diarrhoea) , 
and hot compresses are to be applied to the belly, or a spice or mustard 
plaster used instead. (See article on Diarrhoea.) Vomiting when 
excessive is to be treated in the manner described under that head. 
The after-treatment of acute gastro-enteritis is very important, both in 
respect to food and drugs. Predigested foods are, therefore, in many 
cases indispensable, and a carefully regulated diet is a sine qua non. 
The abdomen should be protected from cold by a flannel binder. 



GLAUCOMA. 

Glaucoma, a disease dependent upon an increase of intraocular 
pressure, appears in an acute or a chronic form. The affection in 
general terms is characterized by halos appearing about artificial lights ; 
periods of obstruction of sight; shrinking of the nasal half of the field 
of vision; narrowing of the anterior chamber of the eye; anesthesia 
of the cornea; and increased tension of the eyeball. In the "glau- 
comatous attack," or acute glaucoma, the injection of the eyeball is 
intense; the lids swell, there is photophobia, the cornea is steamy, the 
pupil dilated and motionless, the tension of the eyeball is greatly raised 
and the globe cannot be dented by the palpating fingers, and the vision 
rapidly destroyed. The condition may be mistaken for iritis or acute 
conjunctivitis — a fatal blunder. 

Acute glaucoma should be treated locally with myotics. Of these the- 
best are eserine, in the form of the sulphate or the salicylate, in a strength 
of 1 to 4 grains to the ounce, and hydrochloride of pilocarpine in a 
strength of 2 to 5 grains to the ounce. One drop of such a solution 
should be instilled with sufficient frequency to contract the dilated 
pupil and to keep it in a state of contraction. The action of the 
myotic may be enhanced by the application of hot compresses and 
corneal analgesia established by the use of dionin in 5 per cent, solution. 
Atropine and all mydriatics are strictly contraindicated. Internally 
full doses of salicylate of sodium should be administered. If the pain 
is very severe there is no objection to a hypodermic injection of mor- 
phine. The surgical treatment of acute glaucoma is usually necessary, 
preferably a broad iridectomy, and this operation should be performed 
unless the myotics are speedily efficacious. 

In so-called chronic glaucoma, in which there are no inflammatory 
or congestive symptoms, but in which there is a progressive atrophy 
of the optic nerve with cupping, associated with diminution of the 



GONORRHCEA. 785 

light-sense and contraction especially of the nasal field of vision, 
and in which the diagnosis is made by means of the ophthalmoscope 
myotics are useful and should be employed in a strength not so great 
as that recommended for acute glaucoma, but with sufficient frequency 
to maintain a contracted pupil. The intraocular tension should be 
frequently tested with a tonometer. Should myotic action fail, or should 
the disease progress in spite of them, iridectomy or one of its substitutes 
may be employed, but the best surgical procedure is an operation which 
creates a filtering cicatrix; for example, Lagrange's combined iridectomy 
and sclerectomy, or Elliot's corneoscleral trephining or iridotasis. 



GONORRHOEA. 

The therapeutics of urethritis depends upon whether it is acute or 
chronic, and is modified by the seat of inflammation — a posterior 
urethritis not being amenable to the same treatment which cures the 
disease in the penile portion of the urethra. 

The membranous and prostatic portions of the urethra constitute 
its posterior part. They are surrounded by layers of powerful muscles 
which play the part of vesical sphincters. Hence, hand injections 
usually pass to, but not beyond, its membranous part, and are useless 
if administered with the intention of combating inflammation of the 
posterior urethra. Gonorrhoea is rarely confined to the anterior urethra. 
A common cause of gleet is the omission of measures calculated to 
cure the deep inflammation. 

Bactericides, used at one time because of this quality, and on the 
theory that what can be accomplished by them in the culture-tube is 
indicative of what can be expected of them when applied to an infected 
urethra, depend for their value in part only upon their bactericidal 
power, since they reach only the surface, and are futile against deep 
infections. Their major value depends upon the degree of inflam- 
matory reaction excited by them. 

The prophylaxis of gonorrhoea is comparatively simple. In the 
female mediate contagion occurs, and in girl babies is frequent. It 
can be avoided by cleanliness. 

Immediately following exposure, urination, momentarily interrupted 
several times by closing the meatus with the finger, a thorough washing 
of the glands, penis, and prepuce with soap and water, and an instilla- 
tion of 20 drops of a 5 per cent, freshly prepared protargol solution 
into the open lips of the meatus, by means of an eye-dropper, will usu- 
ally prevent the development of gonorrhoea, even though gonococci 
have been deposited on the meatal surface. 

When the symptoms of infection have developed, providing treatment 

be instituted before there has been deep penetration by the gonococci, 

destruction and elimination of the infection is still possible. When 

a patient presents himself within a few days of exposure with a slight 

50 



786 DISEASES. 

discharge, made up in the main of squamous epithelium and showing 
gonococci, he is given a three-ounce bottle of a 5 per cent, solution of 
protargol (freshly prepared), and is directed to inject by means of a cone- 
nozzled urethral syringe the first three inches of his urethra every two 
hours during the day and twice at night, urinating first in each instance 
and dropping a few drops into the open lips of the meatus before mak- 
ing the injection. The injection is confined to the meatal three inches 
by pressing the penis at or behind the peno-scrotal juncture between 
the little and ring fingers of the holding hand. When the bottle of 
protargol solution is half empty it is filled with distilled water, this 
refilling being repeated as required for five days. The desired degree 
of inflammatory reaction is characterized by a thin, slightly blood- 
stained serous discharge; there should be no severe pain after the first 
injection or other sign of hyperacute inflammation. The gonococci 
usually disappear in the first twenty-four hours. After five days, even 
in the absence of gonococci, there may persist a slight muco-purulent 
discharge, best treated by astringent injections. 

When the patient presents himself with a frankly purulent discharge 
teeming with gonococci, the treatment may be general or local — a com- 
bination gives the best results. 

The constitutional treatment always indicated has for its end: 1. The 
best obtainable condition of general health, since cure, though helped 
by medicaments, is dependent on tissue resistance. 

2. An unirritating condition of the urine. This implies bodily quiet, 
perfect digestion, regular evacuations from the bowels, and a urine 
reaction neither strongly acid nor the reverse. 

3. The avoidance of local congestion. Constipation, sexual excite- 
ment, bodily fatigue, alcohol, and surface chilling are the common fac- 
tors which produce local congestion. 

4. Free diuresis. Water drinking short of the extent which would 
interfere with gastric digestion. Milk or buttermilk diet. 

5. Drugs which in their elimination render the urine antiseptic and 
stimulating. These must be given with caution, and never to the ex- 
tent of lessening the appetite or irritating the kidneys. Salol, urotropin, 
santyl, copaiba, phenyl salicylate — these properly used are distinctly 
helpful. An excellent formula for the administration of balsam is the 
following : 

I$— Olei santali gr. v (0.3). 

Balsami copaibse ti^v (0.3). 

Olei cinnamomi tt£J (0.06). — M. 

Pone in capsulam No. i. 
S. — These capsules should be taken one hour after meals, from six to twelve 
being administered a day. 

The Lafayette or compound copaiba mixture still retains a popu- 
laritv incident to its beneficial effect : 



GONORRHCEA. 787 

1$ — Copaibae §j. 

Liquor hydroxidi potassae f 5 ij . 

Fluid extract! glycyrrhizae f§ss. 

Spiritus a3theris nitrosi f § j . 

Syrupi acacise f o vj . 

Olei gaultherise gtt. xvj. — M. 

S. — One tablespoonful after each meal. 

When internal treatment is depended upon entirely, the dosage is in- 
versely proportionate to the intensity of the inflammatory reaction — 
indeed, this principle applies both to the general and the local treatment. 

Local Treatment. — An infected urethra may be treated either by irri- 
gation or injection. The irrigation may be accomplished by a fountain- 
syringe and either a short nozzle or a catheter, or by a large piston syringe 
and a catheter. 

Irrigation. — The choice of lotion is of minor importance. The famil- 
iarity of the surgeon with the degree of inflammatory reaction he may 
fairly expect from the lotion of his choice is of major importance. 

A satisfactory treatment consists in thoroughly and repeatedly 
flushing the urethra with permanganate lotion. This may be accom- 
plished by means of a fountain-syringe and a blunt, flattened, conical 
nozzle of such size that when its extremity is passed into the meatus 
its sides will be grasped so tightly that gentle pressure upon the 
nozzle will prevent regurgitation of fluid. The bag is filled with hot 
permanganate solution, 1 : 6000, and is elevated six feet above the 
level of the bladder. After first thoroughly washing the glans and 
lips of the meatus the nozzle should be inserted and held firmly in 
place until the entire anterior urethra is distended, when the nozzle 
should be slightly withdrawn and the urethral contents allowed to 
escape. After this has been repeated several times the nozzle is held 
firmly in place until 3 or 4 ounces of solution have passed into the 
bladder. This treatment should be repeated night and morning for 
at least a week, the strength of the permanganate solution being 
gradually increased up to 1 : 2000, if undue irritation is not caused by 
such increase. If at the end of a week no gonococci can be found, 
the irrigations should be continued once daily for four days, supple- 
mented by astringent injections. When gonococci persist, the irriga- 
tions should be continued for two or three weeks. 

Injections. — When this method of irrigation cannot be practised, a 
syringe with a conical nozzle and with a capacity of at least 1 ounce 
may be employed; this should be used two to six times a day, two 
syringefuls of the dilute lotion being injected immediately after urina- 
tion. The liquid should be forced in very gently, being allowed to flow 
out by slightly lessening the pressure of the nozzle upon the meatus 
when the anterior urethra is full. When large injections are attempted 
by the ordinary small urethral syringe, the frequent application of the 
latter to the meatus occasions much irritation. It is desirable that 
the injections should pass back into the posterior urethra, since this 
portion of the canal is usually involved in acute inflammation. 



788 DISEASES. 

A hyperintense reaction, as evidenced by marked swelling and 
increase in pain and ardor urinse, indicates lessening the strength of 
medication and the frequency of application. 

The syringe of choice should have a conical nozzle, and an efficient 
and smoothly working piston. Urijiation always precedes injection, 
and since the urethritis is practically always total, it is desirable that 
the solution should pass back into the posterior urethra. 

The following prescriptions used as hand-injections are among the 
most efficacious in checking persistent discharge: 

1$ — Nargol, argyrol, vel protargol . . . . gr. iij (0.20). 

Aquae destillatae o iij (90.0).— M. 

Or, 

1$ — Fluidextracti hydrastis (colorless) . . f5iv (16.0). 

Bismuthi sublactatis 5vj (24.0). 

Glycerini f5iv (16.0). 

Aqua- destillatse q. s. f§vj (180.0).— M. 

Hf — Zinci sulphatis gr. xx (1.3). 

Plumbi subacetitis gr. xv (1.0). 

Aquae camphorse foj (30.0). 

Aquae destillatse q. s. ad. fgvj (180.0). — M. 

When injections are intensely painful, or their use following the 
immediate discomfort is not attended by a local feeling of betterment 
in acute cases, they are probably doing more harm than good. This 
point is determined by withdrawing them for a day or two, or substi- 
tuting for the medicament hot normal salt solution. 

When the gonorrhoea has already assumed a markedly inflamma- 
tory type, with swelling and oedema of the penis, redness and ever- 
sion of the meatus, and great sensitiveness of the urethra, and seems 
to be aggravated by mild irrigations, the penis should be wrapped in 
cloths kept wet with dilute alcohol or lead-water and alcohol. With 
the subsidence of acute inflammatory symptoms and the appearance 
of copious discharge the injection treatment may be inaugurated. 
It must be remembered that injections may in themselves prevent 
the discharge from entirely disappearing. Hence, as the symptoms 
ameliorate the injection should be made less frequently, finally being 
entirely omitted for some days if the discharge seems to continue 
longer than usual. 

Obstinate chordee may require bromide of potassium and chloral. 
Of these a drachm of the former must be given at bedtime, and 10 
grains (0.60) of the latter; this may be repeated in the night if painful 
erections persist. Opium or belladonna suppositories, or hypodermic 
injections of morphine, gr. J (0.015), and atropine, gr. -gV (0.001), will 
prove satisfactory. The patient should be instructed to take a prolonged 
hot bath before going to bed, and to rise during the night to pass water. 

Ardor urinse is usually relieved by the use of demulcent drinks and 
by the employment of bicarbonate of sodium or citrate of potassium 
in sufficient doses to render the urine but slightly acid. Either of 
these drugs is conveniently administered in the form of compressed 



GONORRHCEA. 789 

tablets, taken one or two hours after meals in 10-grain (0.6) doses. 
The instillation into the urethra, by means of an eye-dropper, of a 4 
per cent, solution of cocaine a few minutes before urination markedly 
diminishes the burning. Finally, this symptom may often be relieved 
by instructing the patient to pass water with the penis submerged in 
a vessel containing hot water. 

Where the inflammation is of a high grade and attended by fever 
and general malaise, rest in bed, milk diet, and the administration of 
6 minims (0.40) of tincture of aconite, repeated every two or three 
hours, is followed by marked relief. 

The distressing symptoms of acute posterior urethritis do not usually 
develop until the disease of the penile portion of the urethra has run a 
course of two or three weeks. During the very acute symptoms local 
treatment applied to any portion of the urethral canal probably aggra- 
vates the condition, and even the internal administration of balsams 
and antiseptics must be employed with very great caution if at all. 
Hence, when in the third week of gonorrhoea frequent urgent and 
painful micturition indicates an acute exacerbation of posterior ure- 
thritis, suspension of all active treatment is indicated. The bowels 
are kept open; the diet is carefully regulated; the urine is rendered 
bland, unirritating, and antiseptic; repeated warm baths are ordered, 
the painful symptoms being controlled by opium and belladonna. 
"When the acute symptoms subside, the quantity of antiseptics taken 
by the mouth may be increased, balsams may be added, and local 
treatment may be directed first to the posterior urethra, after the cure 
of which the anterior urethritis should receive attention. It has been 
stated already that injections forced into the meatus rarely penetrate 
beyond the bulbous portion of the urethra; hence to influence the 
deeper portions of this canal some other method of applying drugs 
must be devised. This end is best accomplished by means of the 
gravity-bag and short conical meatus nozzle or the instillator. 

The use of the instillator is indicated when total flushings are 
unavailing. 

The patient is first instructed to empty the bladder of a portion of 
its contents; by this means the urethra is flushed out. The anterior 
urethra is then irrigated by means of the bag and short nozzle, after 
which the instillator is passed until its tip has entered the membranous 
urethra. From ten to twenty drops of the solution of choice are then 
injected, and in their backward flow bathe the entire membranous 
and prostatic urethras. Protargol, 0.5 per cent., or silver nitrate, 0.1 
per cent., are the medicaments of choice. The treatment should be 
repeated every third day, and should be preceded by gentle prostatic 
massage. Instillation may be given through a catheter passed till its 
eye reaches the prostatic part of the urethra. By means of a syringe 
the injection of choice then can be driven in. This fluid enters the 
bladder, and is passed with the urine at the next act of micturition. 



790 DISEASES. 

Chronic Gonorrhoea. 

Chronic gonorrhoea differs from the acute form in the fact that the 
inflammation is distinctly localized in certain portions of the urethra, 
and does not invade the whole canal with uniform intensity; hence, 
efficient treatment must be directed not to the whole urethra, but to 
the diseased areas. Foci of chronic urethritis are usually found either 
in the bulbous portion of the urethra or in the membranous or pros- 
tatic portion. If the disease is located in the anterior urethra, it will 
commonly be found to depend upon the existence of a stricture of 
large calibre. The passage of sounds of full size — cutting the meatus 
if this is necessary for their introduction — will be followed by prompt 
relief in such cases. The sounds should be used not more fre- 
quently than twice a week, and should be preceded by mild antiseptic 
irrigation, best effected by the gravity-bag and short urethral nozzle, 
irrigating daily with silvol, argyrol, or protargol (1:3000 to 1:500), 
silver nitrate (1 : 5000), mercurol (1 : 2000), or potassium permanganate 
(1:2000 to 1:500). When the general catarrhal condition is ma- 
terially modified, by means of an ordinary urethroscope, the focus 
of inflammation may be exposed, and may be treated directly by 
strong astringent solutions carried in by means of a brush or by ab- 
sorbent cotton secured to the extremity of a long applicator. Nitrate 
of silver or sulphate of copper, 20 grains to the ounce (1.3-30.0), may 
be employed. Unna has devijed a most successful treatment for 
obstinate cases of gonorrhoea. He advises coating the sounds with 
the following mixture: 

1^— Olei cocae giij (90.0). 

Cerse flavi . ,..',.,. 5ss (2.0). 

Argenti nitratis . . . . . . . gr. xv (1.0). 

Balsami Peruviani 3ss (2.0). — M. 

This is liquefied in a water-bath ; the sounds are dipped in it and are 
then hung up to dry. On being passed the heat of the body melts 
the coating. Practically their employment is often followed by 
brilliant results. This formula should be prepared by the following 
plan: Rub the balsam of Peru in a mortar with 20 drops of diluted 
alcohol to thin it. Dissolve the silver nitrate in about 15 drops of 
distilled water and add with constant stirring to the balsam solution 
until it is a uniform mixture. To this add gradually with constant 
stirring the cocoa butter and yellow wax previously melted together on 
a water bath and allow to congeal. 

Chronic posterior urethritis must be treated by remedies applied 
directly to the diseased area. The silver salts are more commonly 
successful than any other medication. By means of Ultzmann's 
instillator 5 to 10 minims (0.3-0.60) of a solution varying in strength 
from 0.1 per cent, to 5 per cent, may be employed. Irrigations are 
also serviceable; but previous to their employment the prostatic 
follicles should be emptied of their purulent contents by massage 
through the rectum. 



GONORRHCEA. 791 

Finger recommends the following ointment: 

fy — Argenti nitratis vel cupri sulphatis . . gr. xv (1.0). 

Lanolini giij (90.0). 

Olei olivae 5iss (6.0).— M. 

By means of an ordinary catheter — which is first filled, then intro- 
duced until its eye reaches the prostatic portion of the urethra — a 
definite quantity of the ointment can be forced into the canal by a 
graduated rod. 

Frequently the therapeutic influences of cold, together with pressure, 
are found beneficial. The best means of combining these two remedies 
is found in the psychrophore, an instrument in the shape of a sound, 
but so arranged that a stream of water flows through its interior. 

It must be borne in mind that chronic gonorrhoea is commonly due 
to unskilful or not sufficiently prolonged treatment of the acute stages. 
Not only should the treatment of acute gonorrhoea be continued until 
the gonococci have entirely vanished, but for fully two weeks after 
the disappearance of all symptoms of inflammation. The same rule 
holds good in regard to the chronic manifestations of the disease. 

Per contra, it must not be forgotten that long-continued irritant 
treatment may in itself indefinitely prolong a urethral discharge. 

There is a mucous secretion which quite frequently follows a gonor- 
rhoea, but which is in no way dependent upon the persistence of this 
disease. Microscopic examination will at once determine its nature. 
It is probably most rapidly cured by attention to general hygiene and 
by tonic and supporting treatment. 

A urethritis due to the micrococcus catarrhalis which exhibit the 
staining reactions of the gonococcus and can be distinguished from 
the latter only by cultural studies, differs from gonorrhoea only in the 
comparative mildness and brevity of the untreated course. It recovers 
in from two to four weeks without treatment and almost as quickly if 
treated not too vigorously. 

Complications of Gonorrhoea. 

Balanitis and balano posthitis are treated by perfect cleanliness. 
The discharge must be thoroughly washed out, and the surface must 
be dried and isolated. The thorough cleansing of the parts is best 
accomplished by weak astringent solutions, such as the chloride of 
zinc, 4 grains to the ounce (0.25-30.0), 1 per cent, boric acid, or 1.5 
per cent, phenol; nitrate of silver is particularly valuable, and in 
the proportion of 1 grain to the ounce (0.06-30.0) will be found 
sufficiently strong for use as a wash or injection. The superficial 
ulcerations may be further touched with the solid stick of the nitrate 
of silver. The prepuce having been retracted and the parts thor- 
oughly washed, dusting-powder, such as tannin or oxide of zinc, is 
distributed over the surface of the inflamed parts; the glans is then 



792 DISEASES. 

covered with a thin layer of absorbent cotton and the prepuce drawn 
forward. This dressing is to be repeated three times daily. 

If the phimosis is so tight that the prepuce cannot be retracted, 
cleansing, astringent injections, and wrapping the penis in one or 
two thicknesses of gauze or other thin fabric, constantly kept wet 
with dilute lead-water, will be the treatment indicated. If, in spite 
of this treatment, inflammatory symptoms become more marked, 
splitting the foreskin or circumcision is indicated. 

Prostatitis is a rare complication, and in its early course presents 
the symptoms of posterior urethritis. Where the acute symptoms are 
fairly developed direct local treatment is of little avail. Rest in bed, 
light diet, careful regulation of the bowels, medication to render the 
urine bland and unirritating, elevation of the pelvis, prolonged hot 
baths, rectal ice-bags, and the administration of morphine and bella- 
donna, either by means of suppository or by hypodermic injection, 
represent the general treatment of all inflammatory conditions at or 
about the neck of the bladder. In the great majority of cases pros- 
tatitis undergoes prompt resolution, and this is more powerfully influ- 
enced by rectal irrigation than by any other method of treatment. 
For this purpose a two-way rectal tube must be employed, the nozzle 
of which is directed against the projection of the prostate into the 
bowel. From 2 to 4 quarts (2 to 4 litres) of normal saline solution, 
either very cold or as hot as can be borne, are allowed to flow into 
the rectum by gravity, this arrangement of the tubes allowing an 
injection to flow out as rapidly as it flows in. This treatment should 
be repeated three or four times a day. When, in spite of careful 
treatment and the free use of anodynes and antispasmodics, there is 
retention of urine, a soft catheter should be passed into the bladder 
and allowed to remain there. 

If general and local symptoms denote abscess-formation, the pus 
should be evacuated by perineal incision as soon as its definite loca- 
tion can be determined. It is true that the pus collection usually is 
spontaneously discharged into the urethra, but this result cannot cer- 
tainly be depended upon, and, at best, is an unsatisfactory termina- 
tion of the trouble. 

When the inflammation runs into a chronic type, the treatment 
suitable for chronic posterior urethritis is indicated — namely, the use 
of large cold steel sounds, massage, and local applications to the pros- 
tatic urethra. In addition, rectal injections, by means of the two-way 
tube, are very efficient in relieving symptoms. 

Epididymitis as a complication of acute urethritis usually develops 
in the third week of the disease incident to overactive local treat- 
ment, sexual excitement, bodily activity, dietetic error, or constipa- 
tion. In its hyperacute form it is attended by pain of crippling 
intensity, confining the patient to bed. 

The testicles should be supported by a handkerchief bandage, the 
base of which is passed beneath the scrotum, while the ends and 



GONORRHCEA. 793 

apex are secured in front to a circular band passing about the waist. 
To combat the agonizing pain saturated solution of magnesium sul- 
phate is employed or a 5 per cent, guaiacol ointment. These or other 
applications usually must be supplemented by hypodermic injections 
of morphine. Puncture with a tenotome is, in case of excessive swell- 
ing, at times advisable, or in hyperacute cases free incision and drain- 
age. This when the local and constitutional symptoms of pus under 
tension are progressive. During the period of acute inflammation local 
treatment to the urethra is contraindicated. 

On the subsidence of the acute inflammatory symptoms confine- 
ment to bed is no longer needful, providing the testis is properly 
supported by a suspensory bandage. This must be so arranged as to 
apply uniform pressure and at the same time exert the resolvent 
influences of heat and moisture. This end is attained by enveloping 
the entire scrotum in a thick sheet of absorbent cotton or of lambs' 
wool, applying over this a sheet of rubber dam and, finally, a properly 
fitted elastic jock-strap. The gauge as to the efficacy of this dressing 
is the comfort it affords. 

"When the acute symptoms have disappeared attention must be 
directed to the removal of infiltration, which if it persists may be a 
cause of sterility. This is accomplished by the continuance of heat, 
moisture, and pressure; by local applications, such as iodine gr. iv 
(0.25) in lanolin gj (30.0), or of equal parts of mercury ointment 
and belladonna ointment, or by ichthyol, with lard, half and half, and 
bv the internal administration of iodide of potassium, 3 to 5 grains 
(0.20-0.30) three times daily. 

Gonorrhoea in the Female. 

The symptoms of acute gonorrhoea in the female are usually so 
mild that the attention of the physician is rarely called to the disease 
until it has reached its chronic form and has invaded the uterus and 
its appendages. "When, however, acute urethritis is found, the treat- 
ment, both local and general, is conducted on the same principles as 
when the disease attacks the male urethra. During the most acute 
stage no local treatment is advisable, but subsequently injections can 
be made with the ordinary hard-rubber syringe, not more than a 
drachm and a half of the liquid being employed at a time. If the 
urethral discharge persists, the seats of the suppuration are readily 
found by the endoscope tubes, and treated directly by applications of 
strong solutions of nitrate of silver or sulphate of copper. The results 
of treatment are commonly satisfactory. 

Acute vaginitis is not very frequently observed, excepting in infants 
and young girls. In addition to the general treatment of inflam- 
mation, local treatment directed to cleansing thoroughly the inflamed 
surfaces of discharge and acting upon them by a strong antiseptic 
lotion is indicated. The patient is instructed to irrigate the vagina 



794 DISEASES. 

three times daily with 2 pints (960 mils.) of bichloride-of-mercury 
solution, 1:4000, thrown in by means of a fountain syringe. For 
this fluid to reach every portion of the diseased mucous membrane 
it is necessary that the patient should lie upon her back with the 
hips elevated. Before rising a pledget of absorbent cotton is placed 
between the labia. During the most acute stage of vaginitis hot 
saline injections and prolonged hot sitz-baths are indicated. In 
addition to the antiseptic irrigations which the patient is directed to 
make, the physician should every second day insert a speculum and 
paint every portion of the diseased mucous membrane with nitrate- 
of-silver solution varying in strength from 4 to 40 grains to the ounce 
(0.25-2.60: 30.0). The vagina should then be packed with tampons of 
absorbent cotton, which may be dusted with astringent medicaments. 
Vulvitis corresponds to balanitis in the male, and is treated in a 
similar manner. Cleanliness is the most essential point in securing 
a cure. The parts are thoroughly washed with weak antiseptic 
lotions, and the abraded mucous surfaces are kept from coming in 
contact by means of a piece of sterile gauze soaked in mild astringent 
solution. Vaccine treatment is indicated for chronic gonorrhoea. 

GOUT. 

Gout is a word used to signify a series of manifestations occurring 
chiefly in those who have led an inactive life devoid of exercise, have 
lived on the fat of the land, and partaken more frequently of alcoholic 
beverages than of water; or it occurs in persons who do not live in 
this way, but whose ancestors have done so, and have transmitted 
to them the gouty taint or diathesis; or, once more, in those who 
have had poor food for a long time. In other words, it is a disorder 
of nutrition and metabolism. Very few Americans have gout in its 
marked and characteristic forms, owing to the active life they pur- 
sue, and to the fact that the inhabitants of the Western hemisphere 
drink large amounts of water, thereby continually dissolving effete 
matters in the system and washing them away. Nevertheless many 
Americans suffer from what may be called lithsemic symptoms, which 
are due to lack of exercise, overeating, and perverted metabolism. 

The therapeutic importance of pure water in this state is remark- 
able, but the so-called lithia waters depend for their value more upon 
their freedom from lithium salts than upon their presence. When a 
patient goes to medicinal springs, by continually drinking water he 
washes out the kidneys and prevents deposits of effete matters 
throughout the body. In a gouty individual the liquids of the body 
may be said to be so overladen with salts that they deposit them 
wherever a spot is found which is easy of access, just as water laden 
with lime forms a deposit on the sides of its bed in times of drought 
and dissolves and removes these formations when a freshet takes 
place. Very often, when such waters are not attainable, satisfac- 



GOUT. 795 

tory results will be obtained from ordinary distilled water, the insipid 
taste of which can be overcome by charging it with carbonic acid 
gas. 

When an acute attack of gout comes on, it is generally situated, as 
is well known, in the joint of the big toe, but it may involve any 
part of the body, even to the heart and the abdominal viscera. By 
far the best remedy for the relief of the pain, if it is unbearable, 
is morphine, which should be given hypodermicalk. At the same 
time the best remedy for gout that we have, colchicum, should be 
freely given until the patient shows the full effect of the drug, as 
evidenced by gastrointestinal discomfort or pain and slight laxity of 
the bowels. The drug should be used in the form of the wine of 
the seed, in the dose of 40 minims (2.6) at first, and increased 
by 2 minims (0.12) every four hours until relief is obtained or 
symptoms of overdose appear as noted above. In other instances 
the method of administration suggested in the article on Colchicum 
may be resorted to. 

Many physicians at the present time prefer the somewhat more 
agreeable method of using colchicum in the form of colochicine sali- 
cylate, which is a mixture of colchicine and oil of gaultheria, about 
T hy grain (0.0006) of colchicine being present in each capsule and 3 
to 6 being given each day, at intervals of a few hours. 

The local treatment of gout, when it is active, consists in the appli- 
cation of a number of remedies. For hospital practice a very useful 
mixture is made by adding 1 part of bicarbonate of sodium to 9 parts 
of linseed oil. The joint is then wrapped in a piece of lint soaked 
with this concoction. In other cases collodion may be applied in one 
or two good coats, not more, with relief, and in still others oil of pep- 
permint has been recommended. It is to be remembered, however, 
that the inflamed joints are not to be treated by depletion through 
leeches or bleeding, as by this means they ultimately become worse; 
or, in other words, the treatment of gouty inflamed joints is not iden- 
tical with that of inflamed joints from other causes. When the pains 
of acute gout are very severe at night, potassium iodide, in the dose of 
15 grains (1.0) at four or five o'clock in the afternoon, will sometimes 
give relief; this drug should always be combined with colchicum if 
the disease is subacute or chronic. 

In chronic gout, except during the acute exacerbations of the dis- 
ease, colchicum is almost useless, but potassium iodide should be 
pushed to the point of iodism if the trouble be painful. Here diet 
forms an important part of the treatment, and should consist of foods 
which are not fatty nor rich, but plain and nourishing. Milk and 
eggs, the white meat of chicken, and fruits, cooked without sugar 
being added, are allowed, tea and coffee being used only in modera- 
tion. If any wine is taken, it must be followed by copious draughts 
of pure water, and this last article should be used ad libitum. On 
the other hand, pastries, and, more than all, sweet wines, are the 



796 • DISEASES. 

worst things that such a patient can take, and must be absolutely 
prohibited. 

The insomnia of chronic or subacute gout is best overcome by 
strontium bromide and chloral, the former drug being the safest and 
best. Barbital or barbital sodium are also useful. 

Nothing should be done in the neighborhood of gouty joints which 
will injure the skin, as it is easily disorganized and its injury may lead 
to erysipelas. Where the deposit around a joint is very great and 
the normal movements are impossible, relief is often obtained by the 
application of a solution of citrate or carbonate of lithium, 5 to 10 
grains to the ounce (0.30-0.60 : 30.0) of water, on lint wound around 
the parts. Where the skin is broken and will not heal, this treatment 
often permits healing by dissolving the crystals in the wound which 
prevent approximation of the edges and cause local irritation. 

Iodine ointment, or the tincture of iodine, is often placed around 
chronic gouty joints with advantageous results. 

A standard remedy in subacute or chronic gout is arsenic, and its 
administration in the form of 3 minims (0.20) of Fowler's solution, 
with either perfectly pure or lithiated water, is always to be resorted 
to when the iodides and colchicum are temporarily abandoned. If 
anremia is present, arsenic is particularly indicated, and cod-liver oil 
and syrup of the iodide of iron are also of value in this state. Gouty 
patients should take as much exercise and be in the fresh air and sun- 
shine as much as possible. 

We find, therefore, in conclusion, that the use of large amounts of 
pure water free from salts, and the administration of colchicum, 
potassium iodide, and arsenic are the greater points about which 
treatment should centre. In those cases where retrocedent gout 
occurs the heart must be supported by stimulants, particularly by 
hypodermic injections of ether, until the slower drugs can act, by heat 
over the belly, by the use of opium to allay irritation, except when the 
brain and kidneys are seriously affected, by the use of diuretics and 
alkaline drinks, and finally by counterirritation in the shape of a 
mustard plaster placed over the abdomen or chest as the case may 
require. 

HAY FEVER. 

(See Pollen Proteins, Part III.) 

HEADACHE. 

(For Neuralgic Headaches, see Neuralgia; for Bilious Headache, 

see Biliousness.) 

Probably no single source of pain compares in its frequency to 
headache, chiefly because it is essentially a symptom of many dis- 
ease processes or functional disturbances. It may arise from con- 



HEADACHE. 



797 



stipation or eye- strain, from brain disease, from anaemia, from uraemia, 
from plethora, from nervous breakdown, and from a multitude of 
causes which, if they were all recounted, would cover many pages of 
this book. 1 In many instances the employment of a mild laxative, 
which will cause the bowel to empty itself thoroughly, is a necessity. 
In others a careful measurement of the amount of urine passed in the 
twenty-four hours will show that the urinary secretion is deficient in 
liquids and solids, so that effete and poisonous materials are retained 
in the blood, which produce headache. For such cases, if the urine is 
acid, the frequent use of Vichy water (Celestins Spring), to which is 
added a little bicarbonate of potassium as a diuretic, will prove of great 
service. If the urine is alkaline, 10 grain (0.60) doses of ammonium 
benzoate three times a day are often useful. 

Congestive headaches, dependent upon engorgement of the cere- 
bral vessels with blood, are to be treated in a number of ways. If 
any direct cause, of congestion can be discovered, this must, of course, 
be removed. So far as the direct application of drugs is concerned, 
we find two methods of promoting a cure, according to the cause. 
Thus, if the patient be neurasthenic and feeble, the use of ergot and 
strychnine, which will cause contraction of the dilated vessels, is useful ; 
whereas if the congestion is due to high arterial tension and excessive 
cardiac action, the bromides and the employment of vascular sedatives, 
such as nitroglycerin and aconite, which will produce arterial depres- 
sion and so remove congestion/are indicated. It is to be remembered 
that when the congestion is due to vascular relaxation and weakness 
vascular sedatives are contraindicated. 

The use of a hot mustard foot-bath is of great value, and a mus- 
tard plaster or dry cup applied to. the nape of the neck is often of 
service in congestive headaches, while in severe cases an ice-bag 
applied to the head or leeching behind the ears or on the temples may 
be resorted to. Bleeding often gives relief at once in severe congestive 
headache. 

In nervous women who suffer from headache much comfort and 
relief will often ensue if the top of the head be wet with one of the 
following formulae: 

1$ — Spiritus camphorse foj (30 0). 

Spiritus lavandulae, 

Alcoholis aa fgij (60.0).— M. 

S. — Apply locally. 
Or, 

1$ — Camphorae, 

Olei menthce piperita? . . . . . aa 3j (4.0). 

Chloroformi f §ss (16.0) 

Alcoholis q. s. ad f §iij (90.0). — M. 

S. — Shake the bottle and apply a little of the liquid to the head. 

In other instances bathing the head with cologne-water to which 
have been added 5 grains (0.3) of menthol to the ounce is useful. 



See chapter on Headache in the author's Bedside and Office Diagnosis, Lea & Febiger. 



798 DISEASES. 

Where headache depends upon fatigue, either general or local, 
stimulating treatment is necessary. If eye-strain be the cause, full 
doses of strychnine or nux vomica are of service, but these remedies 
cannot be used if there is much retinal irritability. Proper eyeglasses 
are, of course, indicated in such a case. 

In many instances a combination of caffeine, bromide of potassium, 
and antipyrine is very successful, as follows : 

Py— Caffeinae citratae . ....... gr. xl (2.60). 

Potassii bromidi 3iv (16.0). 

Antipyrinse 3ij (8.0). — M. 

Fiant chartulse No. xx. 

S. — One powder in water as needed. 

Sometimes the caffeine makes the headache more acute, and if this 
occurs only the antipyrine and bromide can be used. (See articles on 
Antipyrine, Acetanilide, and Acetphenetidin (Phenacetin.) 

Another useful prescription is: 

1$ — Extracti guaranse gr. x vel xx (0.60-1.3} 

Extracti apii graveokntis gr. x (0.60). — M. 

Fiant in capsulas vel chartulas vel pilulas No. x. 

S. — One every half-hour until relieved or three are taken. 

Sleep is generally a more useful prescription than any drug, and 
if city life creates so much mental anxiety during the day as to be 
wearing upon the nervous system or make the patient wakeful at 
night, business must be put aside and health and recreation sought 
at a watering-place. Horseback exercise is very useful indeed, and 
should be resorted to by all who can afford it if they are sufferers 
from nervous headaches. Walking is also useful. 

A form of headache which is often very severe, sometimes fleeting, 
sometimes persistent, is that due to gout, and it is to be treated by 
means quite distinct from those named so far. Some practitioners of 
wide experience employ salicylic acid in doses of from 5 to 15 grains 
(0.3-1.0), while others rely on the iodide or acetate of potassium. 
(See Migraine.) Aspirin in 10-grain (0.65) doses is very useful. 

Other cases of a gouty headache require colchicum, particularly 
if the gout be widely distributed in its manifestations, and to these 
Hamilton gives: 

1$ — Vini colchici seminis f §ss (16.0). 

Potassii acetatis 3v (20.0). 

Potassii iodidi 3v (20.0). 

Tincture cimicifugae f ov (20.0). 

Aquse destillatae q. s. ad f oiv (120.0). — M. 

S. — Teaspoonful (4.0) every four hours. 

In cases in which anaemia is associated with the gouty tendency 
Peabody uses the following prescription, the ingredients of which are 
compatible, whereas most of the preparations of iron and salicylic acid 
are incompatible: 



HEART DISEASE. 799 

I*— Acidi salicylici gr. xx (1.3). 

Ferri pyrophosphates gr- v. (0.3). 

Sodii phosphatis gr. j (0.06). 

Aqua- destillatse f oss (16.0).— M. 

S.— To be taken every three hours. 

Cohen has used the following, which is more pleasant to the taste: 

If- Sodii salicylatis • oiv (16.0). 

Glvcerini f o i j (60.0). 

Olei gaultherise • "l** C 1 - 3 )- 

Tincture ferri chloridi f 5iv (16.0) 

Acidi citrici gr. x (0.60). 

Liquoris ammonii citratis, B. P. 1 q. s. ad fgrv (120.0).— M. 

S— Dessertspoonful (8 0) in water twice, thrice, or four times a day. 

(For the treatment of migraine, see Migraine.) 
HEART DISEASE. 

(For Treatment of Angina Pectoris, see p. 671.) 

The writer classifies all forms of heart disease under this heading 
advisedly. In valvular disease the profession understands more and 
more that the mere destruction or laming of this valve or that has 
little to do with the treatment although, the ultimate result of the 
case is somewhat dependent upon these conditions. It matters not 
whether the leak in a valve be minute or great, provided the heart 
can still do its w T ork; the condition of the cardiac muscle is the impor- 
tant factor to be considered. If an irreparable leak exists in a pump 
which cannot be stopped for repairs, the question is not, Can we cure 
that leak? but rather whether w T e can work the pump with enough 
force and rapidity to obtain all the water needed for the maintenance 
of life. Some physicians use heart tonics, such as digitalis, whenever 
they find a valve diseased, as if to mend the broken valve. Nothing 
can be more erroneous, for a valve once injured is never regenerated. 
It is only in those cases which have relaxation of the muscular fibres 
around the orifice that digitalis can cure a murmur of mitral regurgi- 
tation. 

It should be an invariable rule with every physician in examining 
a patient with heart disease to determine whether or not the tissues 
of the body receive their normal blood-supply. If they do not, even 
though the leak is so small as almost to escape notice, treatment is to 
be instituted; but, on the other hand, if the murmur heard on auscul- 
tation is as loud as that of a machine-shop and the tissues are not 
starved, no remedy is needed. Indeed, it not rarely occurs that no 
murmur can be heard in the presence of signs of circulatory feebleness, 

1 Liquor ammonii citratis, B. P., is made by adding 5 fluidounces (imperial meas.) of 
strong solution of citrate of ammonium to 15 fluidounces (imperial meas.) of distilled 
water. The stronger solution of citrate of ammonium is made by taking 12 ounces 
(avoirdupois) of citric a< id, strong solution of ammonia 11 fluidounces, and adding enough 
distilled water to make 24 fluidounces (imperial meas.). 



800 DISEASES. 

because the heart may be too feeble to drive the blood past the leaking 
valve with sufficient force to produce any sound. 

Another very important point in regard to the treatment of cardiac 
disease in children is the remembrance that the stunting of the body 
and the slowness of growth are not merely the result of heart trouble, 
whereby the tissues do not increase in size from lack of nourishment, 
but occur for a special purpose. Let us suppose that a child of eight 
or nine years has scarlet fever or rheumatism, which leaves the cardiac 
valves impaired in function, the question must arise, "Can the heart 
properly fill the bloodvessels?" If the heart can supply the vessels, the 
child lives, but is stunted, because Nature is wise enough to understand 
that the struggling heart has all it can do to supply even a stunted 
frame, and realizes that a rapidly increasing area of bloodvessel surface 
in a growing child would exhaust the cardiac muscle. 

The physician should not permit the parents to worry over this lack 
of growth, but by the use of gentle gymnastics or tonics, and attention 
to the general health, he is often enabled to improve the cardiac 
condition. As soon as this organ is strong enough to permit of growth, 
growth will take place. 

In the general treatment of heart disease the most important thing 
for the physician to prescribe is rest. A tired heart cannot supply an 
active body. A very definite idea of how fatigued the heart muscle is, 
or how much it has failed as the result of myocardial degeneration can 
be obtained by the stair-climbing test. If the heart is normal the 
blood-pressure rises under exercise, but if it is feeble the blood-pressure 
falls. So, too, if the difference between the diastolic pressure and the 
systolic pressure is low this is also indicative of a weak heart as a rule. 

Having made these preliminary remarks, let us turn to the direct 
application of drugs to heart disease, the chief drug in the list being, 
of course, digitalis. 

The value of digitalis may be said to rest upon a number of influ- 
ences possessed by it. In the first place, evidence is constantly accu- 
mulating to show that digitalis increases the nutrition of the heart 
muscle by the stimulating influence which it exerts on the pneumo- 
gastric nerve, this nerve having been partly proved to be a trophic 
nerve of the heart. Aside from any such nervous influence, the heart 
muscle receives a greater blood-supply under the use of digitalis, 
since both diastole and systole are influenced by the drug, the systole 
being more complete and the diastole being prolonged and more 
extensive. 

Two theories concerning the nutrition of the heart muscle through 
its blood-supply have been promulgated. One is, that the coronary 
arteries are filled with arterial blood as the heart drives its contents 
out of the left ventricle into the aorta, or, in other words, during systole. 
The other hypothesis rests upon the belief that the contracting muscle 
prevents a free circulation of blood through the cardiac bloodvessels, 
and that the blood is driven into the coronary arteries during diastole 



HEART DISEASE. 801 

by the pressure in the aorta, the aortic valves being closed. The latter 
view is incorrect so far as the coronary arteries are concerned, for 
they are filled during ventricular systole, and this systolic contraction 
of the muscular fibres urges onward the blood already in the intramural 
vessels. Nevertheless the complete passage of the blood through the 
smaller vessels of the cardiac muscle only takes place as relaxation or 
diastole occurs. The ground for this belief consists in the observation 
that a muscle when firmly contracted always presses upon its supplying 
bloodvessels, and particularly interferes with capillary flow. The 
heart of one of the lower animals, if carefully watched after the chest- 
wall is removed, will always be found to become paler during systole 
and redder during diastole. As the blood everywhere in the body 
nourishes the tissues, not when in the arteries, but while passing 
through the capillaries, it would seem self-evident that, while the 
coronary arteries are filled by the systole or contraction of the heart, 
the nutritive changes and perfect capillary circulation go on during 
diastole. If these premises are true, the increase in cardiac nutrition 
and growth under the action of digitalis is only what one would expect, 
for we have learned when studying this drug that it prolongs diastole 
and increases the force and volume of the systolic wave of blood. In 
other words, digitalis fills the coronary arteries almost to bursting, 
and so, when diastole occurs, not only floods the cardiac capillaries 
with blood, but prolongs the period during which the interchange 
between the blood-stream and tissues takes place. 1 

The value of the regulating or inhibitory influence of the vagus has 
become more apparent with the advance made recently in our know- 
ledge of the physiology of the heart. Thus it has been shown that in 
systole the heart muscle becomes refractory to stimuli and loses its 
irritability, contractility, and conductivity, all of which are restored 
during the diastolic pause. Further than this, the efficiency of the 
heart is apparently in direct ratio to the length of the pause, that is, 
of the period of resuscitation. 

Normally, the heart beats fast or slow according to the demands for 
blood made upon it by the system, and its action is varied by the calls 
which it receives from the tissues. In heart disease, with failure of 
compensation owing to leaky valves, the tissues are starved, and 
continually send messages for more nourishment to the cardiac muscle, 
which finally becomes exhausted by its endeavors to supply their 
wants, and beats faster and faster in its efforts to compensate for the 
leak. If digitalis is given, the vagi render the cardiac action regular 
and effective, acting as a regulator and director of its energies, thereby 
supplying the tissues and using the remaining power of the heart to 
the greatest advantage, in addition to improving its blood-supply by 
the methods already described. The starving tissues of the body 
having been satisfied, as Wood has eloquently expressed it, " the angry 

1 See article on Digitalis in Part II of this book. 
51 



802 DISEASES. 

messengersfrom the periphery cease their callings, and the heart is at 
peace and in comfort." 

From what has been said it becomes evident that this drug (digitalis) 
generally does good when the heart is weak, and we find for this reason 
that cardiac dilatation, simple cardiac failure, or heart-failure depend- 
ent upon the presence of poisons, all indicate its use. 

The mechanism of the action of digitalis in the different cardiac 
valvular lesions still remains to be described, and before doing so the 
author desires to remind the reader that a patient under the full influ- 
ence of digitalis ought to maintain the recumbent posture. (See 
article on Digitalis.) Further, the effect of the drug tends to accumu- 
late, and therefore it should be stopped for several days at the end of 
each week of its use when it is given in full doses. 

Digitalis should be begun in small doses, which can be gradually 
increased in size if need be, except in cases in which great cardiac 
feebleness demands immediate and powerful stimulation, when several 
large doses should be given and smaller doses used later to maintain 
the effect. 

Taking up the most common condition, that of mitral regurgitation, 
we find that in this disease the blood passes, in its normal flow, from 
the left auricle into the ventricle, and, when the ventricle is filled, 
that the cardiac muscle contracts on all sides equally. Normally, the 
mitral valves close the auriculoventricular opening and prevent any 
of the blood from regurgitating, into the auricle, and the greater 
the pressure the tighter they become. Abnormally the blood is still 
pressed upon on all sides as before, and, trying to escape, as do all 
liquids, from pressure, finds that, owing to disease of these valves, it 
can, in part at least, slip back into the auricle from which it came, 
rather than pass out into the high pressure of the arterial system. 
The ventricle, therefore, propels blood in two directions — in the wrong 
way and in the right way. If the leak is large enough to permit of the 
regurgitation of a large part of the blood, then death occurs. Digitalis 
does good in mitral regurgitation because, by increasing the force of 
the ventricle, it increases the friction at both the mitral leak and the 
aortic opening; but, as the aortic opening is a large one and the mitral 
leak a small one, the greater quantity of blood passes out into the cir- 
culation. It also does good because it strengthens the heart muscle 
and contracts the muscular ring which surrounds the auriculoven- 
tricular orifice, therefore rendering it easier for the valves to close the 
mitral opening. The same fact arises for consideration as before — 
namely, that it is not the amount of leak, but the amount of supply to 
take its place, which is the vital question in the case. Rarely relief 
does not occur, and the patient is made worse by digitalis, because the 
leak is increased as much as the normal flow. 

In mitral obstruction the difficulty is that the blood cannot enter 
the ventricle with sufficient rapidity, and this part of the heart con- 
tracts before it is well filled. By the prolongation of diastole the 



HEART DISEASE. 



803 



blood is given sufficient time to enter and the ventricle is filled, send- 
ing out into the system a large wave of blood when it contracts. Fur- 
ther than this, the stimulation of the right ventricle by the digitalis 
enables this part of the heart to overcome the tendency to congestion 
which arises from the obstruction in the left side of the heart. Often 
the right side of the heart must be relieved by venesection and active 
purgation. 

When the obstruction at the mitral orifice is so great that the auricle 
becomes distended and its power impaired so that it cannot well propel 
blood through the auriculo-ventricular opening, it not infrequently 
happens that great arrhythmia develops, not only as to the regularity of 
the heart sounds, but also in respect to the amount of blood which is 
expelled at each ventricular contraction. This irregularity is not alone 
due to stretching and exhaustion of the auricular wall, whereby the con- 
ductivity of the auriculo-ventricular fibres, as they pass through the 
auricular wall, is impaired, but to damage of His' bundle by the in- 
flammatory process originally present, whereby tissue is destroyed, or 
the blood supply of the bundle is interfered with. Such a lesion in 
His' bundle may result in preventing some impulses from reaching 
the ventricle and so beats are missed. (See Digitalis, Part II.) 
Digitalis should be given with great caution, or not at all, in mitral 
stenosis with missed beats, because, by its power of still further decreasing 
the conductivity of His' bundle, it may induce complete heart block so 
that the auricles and ventricles are completely dissociated. Under these 
circumstances, the use of digitalis had better be avoided, or only 

Fig. 131. 



Showing partial heart-block. The auricle beats about 100 a minute. The ventricle only 50 a 
minute. Indication is for atropine. Upper tracing jugular vein. Lower tracing radial artery. 



small doses used, until by rest in bed, purgation, and the use of other 
remedies, such as caffeine, strychnine, or ammonia, the actioji of the 
heart is improved. Atropine in the dose of T ^ ¥ grain (0.0001) four 
times a day is very useful. (See Figs. 131 and 132.) If there is much 
orthopncea and other evidence of circulatory failure, strophanthin or 
strophanthone may be given intravenously, but it is not to be for- 



804 DISEASES. 

gotten that after the use of full doses of digitalis this use of stro- 
phantus may induce sudden cardiac arrest. Strophanthin is given 
in the dose of 1 mil. of a 1 : 1000 solution, put up in ampules. Stro- 
phanthone diluted with salt solution may also be given hypodermically 
in the dose of 1 mil., equal to about gV grain of strophanthin, as it does 
not cause the intense irritation caused by strophanthin, or intraven- 
ously in the dose of 0.5 mil. (See Strophanthus.) 

Fig. 132. 



Same patient after taking -g^ grain of atropine four times a day which caused disappearance 
of heart-block. Auriculoventricular rhythm reestablished. 

There is, however, another condition of the heart, met with most 
frequently in mitral stenosis, called auricular fibrillation, in which 
digitalis may do great good. In this state the auricle does not contract 
at all, but remains dilated, and over its surface fibrillary waves occur. 
No impulses pass to the ventricle from the sino-auricular node by way 
of His' bundle, and the ventricle acts of itself, the auricle being only a 
dilated bag through which the blood passes. The signs of auricular 
fibrillation are a disappearance of the presystolic murmur and the 
development of a ventricular pulse in the jugular veins, best deter- 
mined by the use of a sphygmocardiograph. How the digitalis does 
good is not clear, unless by stimulating the right ventricle it drives 
the blood through the left auricle, and by increasing the power of the 
left ventricle improves the systemic circulation. It also tends to 
block some of the shower of impulses which attempt to cross His' 
bundle. Large doses are usually needful in this state, but they 
should not be continued over two or three days as a rule. Their 
continuance should be controlled by the use of the sphygmocardio- 
graph. (See Figs. 133 and 134.) 

In aortic stenosis there is obstruction to the normal flow of blood 
out of the heart, and the digitalis is needed to increase the ventricular 
force, so that it may overcome the difficulty. 

In aortic regurgitation digitalis, by its stimulation of the heart 
may cause a sufficient output of blood to clear itself of the regurgitant 



HEART DISEASE. 



805 



flow, but in many cases the drug fails because the prolongation of 
diastole gives so much more time for the blood to flow backward into 
the dilating ventricle. The cardiac remedies to be used in such cases 
are strophanthus, in the form of the tincture, dose 5 to 10 drops (0.3- 
0.6); adonidin, dose \ to \ grain (0.015-0.3), and sparteine, \ grain 
(0.3). These remedies may also be used in the other forms of cardiac 
disease where digitalis fails. It is important to remember, however, 
that some cases of aortic regurgitation do improve, at least temporarily, 
under digitalis, by reason of the fact that the weary and dilated muscle 
walls of the ventricle have their toxicity restored by this drug. 

Fig. 133. 



c%Zv 



AkT^- 



c vcHJ^Mv 



Jugular 



Radial 



Showing auricular fibrillation with irregular ventricular contraction. 
Fig. 134. 



Jugular 



Radial 



Shows restoration of normal sinus rhythm and regular ventricular contraction induced 

by full doses of digitalis. 

Murmurs associated with evidences of cardiac failure do not always 
indicate the presence of valvular disease, for dilatation of the mitraj 
orifice may prevent the proper approximation of the valves. In such 
a case digitalis, by overcoming the relaxation, may produce cure of an 
apparent valvular defect. 



806 



DISEASES. 



Physicians often meet with cases of severe valvular disease in which 
there are present a laboring heart, distended jugulars, and cyanosis, 
indicating engorgement of the right ventricle. This is to be relieved 



Fig. 135. 



October 



November 




Paroxysmal tachycardia. No benefit from moderate doses of digitalis. Large doses 
cured. Blood-pressure rose as pulse-rate fell. Dotted-line pressure. 

by free venesection from the arm, and, after the engorgement is removed, 
by the use of a mercurial and a saline purge and digitalis. 

In many cases of cardiac disease there are associated with the heart 
lesion general debility and anaemia. These cases should be treated 



HEART DISEASE. 807 

not only by the use of heart tonics, but also by iron, arsenic, simple 
bitters, and, if constipation is present, by mild purgatives. 

In cardiac dropsy digitalis and the other heart stimulants do good 
by raising blood-pressure and pulse force, and in some instances by 
stimulating the kidneys to increased efforts at elimination. (See 
Dropsy.) In these cases, too, the patient will often be greatly bene- 
fited if he receive every few days a full dose of blue mass and of one 
of the hydragogue cathartics, which will relieve the dropsy and unload 
the portal circulation. A useful formula under these circumstances is 
as follows: 

I$— Extracti sambuci folii gr. ij (0.12). 

Extracti oxydendron arborei . . . . gr. ij (0.12). 

Extracti scillae gr. i (0.016).— M. 

Fiat pilula No. i. 

S. — Take one pill four or six times a day. 

On the other hand, if the heart is feeble and the arterial tension is 
high, not only must sodium nitrite be given to relax the spasm, but in 
addition a cardiac tonic must be employed, which at the same time that 
it stimulates the heart will not raise arterial pressure, as, for example, 
strophanthus, in preference to digitalis, w T hich stimulates the arterial 
system and increases the tension. As digitalis is prolonged in its 
effect and sodium nitrite is fleeting, the digitalis should be given every 
eight or twelve hours, and the sodium salt every three or four hours. 

In cases of threatened ruptured compensation or cardiac fatigue, 
before attempting to lower blood-pressure which is higher than normal, 
the physician must be sure that such a high pressure is not essential 
for the comfort and even the life of the patient, as fibroid, tortuous 
vessels render a high pressure necessary if the circulation is to be 
maintained. In such instances the nitrites do no good and often do 
actual harm. The circulatory strain is best relieved by the use of the 
electric-cabinet bath or any form of hot-air treatment with massage, 
and the use of the iodides may be valuable. 

When compensation is suddenly ruptured and circulatory failure is 
imminent, the use of ether and ammonia is to be resorted to at once, 
and these are to be followed by strophanthin intravenously or stro- 
phanthone intravenously or hypodermically, or by digitalis by the 
mouth or digitalone hypodermically. Pituitrin may also be given 
intravenously, the contents of an ampoule being used. If venous 
turgescence is present great relief often follows free venesection. (See 
Venesection.) 

In cardiac palpitation dependent upon indigestion, this condition 
must be relieved by appropriate digestive remedies; but in that form 
of palpitation due to overexertion or heart strain digitalis is useful. 
Iron is to be used if the irritability is due to anaemia. Tea, coffee, 
tobacco, and excessive venery are to be forbidden. Sometimes mix 
vomica does good by stimulating the heart and nervous system, and 
belladonna seems of great value where arrhythmia is present. In other 



808 DISEASES. 

cases of arrhythmia the patient will be more benefited by the use of 
sparteine, or aconite and digitalis. (See Aconite.) 

In cardiac dilatation and asthenia digitalis is often very useful; 
but should the patient be advanced in years and have a tendency to 
arteriosclerosis, we should, simultaneously, give sodium nitrite or 
iodides to relieve any arterial spasm which resists the action of the 
heart. Very often such patients will suffer from scanty secretion of 
urine and albuminuria, and will develop congestion of the kidneys. 
This may be controlled and greatly relieved by the use of full doses of 
digitalis, say 5 to 10 drops of the tincture every four hours, with 20 grains 
of bitartrate or citrate of potassium every four hours. The addition 
of the alkaline diuretic very greatly aids in the diuretic effect of the 
digitalis in these cases. Sometimes diuresis can only be established 
after free purgation. In some cases it is wise to substitute for the 
digitalis either strophanthus or caffeine. Both should be given freely, 
say 3 grains (0.20) of caffeine, or 10 minims (0.60) of the tincture of 
strophanthus, every four hours. (See Nephritis.) 

In cases of myocardial degeneration arising during the course of 
acute infectious fevers, digitalis is of little value. In chronic myocarditis 
with or without valvular disease it may prove helpful, but if it causes 
irregularity must not be continued. (See Mitral Stenosis.) Usually 
the nitrites should be combined with it in these cases for obvious reasons. 

Cardiac hypertrophy is rarely seen without some other lesion accom- 
panying it, but it may occur from prolonged and excessive exercise or 
other cause. It is to be treated by absolute rest and avoidance of 
excessive exercise, and by moderate amounts of food of a non-stimu- 
lating character. Wines and coffee should be forbidden, and a bella- 
donna plaster may be placed over the praecordium if the action of the 
heart is very excessive. Both palpitation of the heart and cardiac 
hypertrophy are favorably influenced in many cases by aconite or 
veratrum. 

Physicians who are in the habit of examining young men professionally 
will constantly have their attention called to a condition of shortness 
of breath on exertion, palpitation, or violent pulsation of the heart, and 
in some instances the development of severe symptoms which, at first 
glance, may seem to be those of true angina pectoris. In many of these 
youths there will be a history of the excessive use of tobacco, or that 
they have left college, where they indulged in severe athletic exercise, 
such as running or bicycle racing, and have entered business, where 
they lead a most sedentary life. In these cases the condition which 
exists is comparable to that which exists in a steamship whose engines 
are too strong for her hull. The heart, which has heretofore been 
supplying the body of an athlete with blood, now finds itself too 
strong for the sedentary individual. There is probably no remedy 
which will give such good results under these circumstances as aconite, 
in the dose of 1 minim (0.06) of the fluidextract or 5 to 10 minims 
(0.30-0 60 ^ of the tincture three times a day, particularly if at the 



HEART DISEASE. 809 

same time a good belladonna plaster about four inches square is applied 
over the prcecordium. Many cases of tobacco heart, in which there 
is arhythmia, with an excessive cardiac impulse over the prsecordium, 
with palpitation on exertion, will be benefited by aconite used in this 
way; but where the heart seems much depressed, so that the apex 
beat is feeble and the first and second sounds are not clearly heard, 
aconite will seldom, if ever, do good. 

In that form of functional cardiac disorder due to indigestion aconite 
is not capable of producing the results which are obtained in the cases 
which have just been mentioned. It may, however, be used as a remedy 
of value at the same time that the physician is directing his attention 
to the cause of the trouble — namely, the gastro-intestinal disorder, 
the treatment of which is foreign to this article. Here, again, a con- 
dition of cardiac feebleness contraindicates the employment of this 
drug. 

Passing to the employment of aconite in cases of true cardiac dis- 
ease, we find that a careful study of a certain number of cases will 
soon show the physician that this drug is capable of doing more good 
in some instances than is digitalis. 

The history of the following case illustrates this point: A man, 
aged nineteen, was brought to the hospital suffering from aortic regur- 
gitation, and as a result of this was attacked with dyspnoea on the 
slightest exertion, marked cardiac arhythmia, with palpitation, some 
giddiness, and a tendency to nose-bleed. He stated that in the early 
part of the year, and for several years preceding it, he had been a 
deck-hand on a coastwise vessel, where he performed hard manual 
labor, notwithstanding the condition of cardiac disease which was 
present, and of which he knew nothing. During this time he suffered 
from no symptoms indicating cardiac disorder. In other words, 
compensatory hypertrophy was complete. Because of the exposure 
incident to his work he was forced, under the advice of a physician, 
to earn his living on shore. He was not successful in obtaining em- 
ployment, and a prolonged period of muscular inactivity followed. 
As a consequence the cardiac hypertrophy, which had hitherto been 
compensatory, became excessive, and he suffered from marked cardiac 
palpitation, with a throbbing sensation in the extremities, and from a 
distressing cough. Early in the study of the case it was recognized 
that these disorders were due to the excess of cardiac hypertrophy, 
and not to failure in compensation, and, as a consequence, that a 
cardiac depressant was indicated rather than a cardiac stimulant in 
the shape of digitalis. He was given from 1 to 2 minims (0.06-.12) 
of the fluidextract of aconite three times a day, and during the con- 
tinuance of this treatment was purposely confined to bed. At the 
end of a week so much improvement had taken place in his condition 
that he was allowed to rise and go about the ward as he wished, and 
after four weeks, the medicine being continued during this period, he 
was so improved that he was discharged from the hospital, with no 



810 DISEASES. 

other evidence of cardiac disorder than physical examination would 
show. 

Great care must be taken to differentiate the overaction of the 
heart, when feeble and dilated, from the overaction of excessive 
hypertrophy, the more so as the former is the state more frequently 
met with. If this is not done serious damage may result. An ice-bag 
over the heart is often all that is necessary, in addition to rest, to quiet 
this viscus. 

When aconite is used, rest in bed is essential, in order that the 
heart may not be excited to great activity by exercise of the limbs, and 
also because the recumbent posture permits larger doses of the drug. 

An exceedingly useful treatment of valvular disease with or without 
ruptured compensation is rest in bed without medication. The results 
in some cases are often remarkable. 

Fatty heart occurs in two forms : that in which true fatty degeneration 
has taken place in the muscular fibre, and that in which there is a 
deposit of fat about the heart and between its fibres. Nothing of 
any importance can be done for the first state, except by the use of 
nitroglycerin or by the iodides to relieve arterial tension if it be too high. 
Strophanthus with or without nux vomica may be useful to relieve 
symptoms of cardiac distress. Much can be done for the second 
form. In neither form is digitalis of much value. If given, it should 
be combined with nux vomica, or nux vomica may be given alone in 
full doses. The patient suffering from the second form of heart 
trouble is nearly always obese, and should abstain from fats and rich 
foods, from all sweet wines and malt liquors, from sugars and milk, 
and at the same time take exercise. At first this treatment may cause 
dyspnoea, but by gradually increasing the severity of the exercise 
much can generally be effected in the end, with marked improvement 
in the cardiac action. (See Obesity.) 

Heart disease associated with failure of the muscle may not only be 
treated with drugs, but with other remedial measures, such as gentle, 
active exercise, passive exercise, and baths, the latter being given with 
care to avoid too great shock and for the purpose of improving the 
general circulation. 

The movements are so-called resistance movements, the patient 
slowly flexing and straightening his limbs and neck against gentle 
resistance on the part of an attendant. By this means the circulation 
of blood and lymph in the tissues is aided without tiring the heart. 
These resistance exercises do not, however, agree with all cases. In 
persons with very feeble hearts gentle massage is far better. The rule 
should be never to give enough exercise or massage to cause accelera- 
tion of the respiration or marked increase in .the action of the heart. 
Very feeble cases should have the massage at the first part of the 
treatment, the exercise next, and the baths last. 

Before considering the use of the Nauheim bath it is necessary 
to have a clear conception of what it is and the methods by which it 



HEART DISEASE. 811 

does good. There are six springs at Nauheim, of which three are 
used tor bathing and three for drinking purposes. The latter are not 
of great importance and do not form part of the "cure" in the strict 
sense of the word, although the water from the "Kur" and "Karls- 
brunnen" springs are sometimes sipped in the morning before break- 
fast for their laxative effect. 

The bathing waters are. derived from three sources: No. 12, or 
Friedreich Wilhelms Quelle; No. 7, or Der Grosse Sprudel; and a 
new one, called No. 14. The water of all these is very heavily charged 
with carbonic acid by Nature. So great is the pressure that the water 
is forced upward as high as fifty feet from a vertical pipe-nozzle. In 
the case of springs 7 and 12 the delivery pipe permits the water to 
shoot upward, and it then falls back into adjacent tanks, so that dur- 
ing its rise and fall a large amount of gas is lost, and much of the lime 
and iron held in solution is precipitated in the tanks. This water is 
led to bath-tubs, and if the patient is feeble and the "cure" is just 
beginning, it is often diluted with plain water and sometimes heated. 
This forms the Thermal Sool-bad. 

Other baths are supplied by pipes which carry the water directly 
from the earth without the gas being allowed to escape in any quantity. 
This water sparkles as does soda-water, and is called the Sprudel-bad. 
Still another bath is provided in which there is an outflow opening as 
well as an inflow opening, and in which the patient sits in a tub 
into which freshly charged water is rushing as fast as it runs out. 
This is called the Strom-bad. These baths are all therapeutically 
powerful, but, naturally, the first is not so active as the last. 

The therapeutic value of these baths depends upon their ability to 
cause dilatation of the peripheral capillaries, which thereby relieves 
internal congestions and enables the heart to pump blood more easily 
through the capillaries. They also stimulate the heart by reflex 
nervous action. The method of treating cardio-vascular disease by 
the use of carbonated baths and gentle resistant exercises achieved its 
popularity at Nauheim, Germany. These baths have been duplicated 
in this country at a number of sanatoria and health resorts, but there is 
little doubt that the absence from business or home cares, combined 
with change of scene and methods of living, is chiefly responsible for 
the benefit that accrues in many cases. In properly selected cases the 
baths and exercises do good but they should be given under the direc- 
tion of a physician trained in their use. The indications for this plan 
of treatment may be stated as follows: Functional cardio-vascular 
disorders as seen in overworked men and women, in which cases the 
treatment increases the circulatory tone. So, too, cases showing 
cardio-vascular feebleness after one of the acute infectious diseases 
may be i benefited unless there is evidence of distinct myocardial 
feebleness or degeneration as shown by the stair-climbing test or 
dyspnoea on very slight exertion. Cases of cardiac fatigue due to 
valvular disease with little or no myocardial degeneration and cases 
of discomfort or pain in or about the heart due to the excessive use of 



812 DISEASES. 

tea, coffee, tobacco or alcohol are benefited. It will be seen that 
nearly all these states yield to other methods of treatment, as, for 
example, rest, tonics and small doses of digitalis. 

The contraindications are fairly definite: Valvular disease with 
rupture of compensation to such extent that there is considerable 
oedema and a tendency to the accumulation of fluid in the serous 
cavities, or if the liver is distinctly engorged and tender; cases of 
angina pectoris, well-developed cardiac degeneration, and cases mani- 
festing signs of acute inflammation in the myocardium, endocardium, 
or pericardium. So too in cases of high arterial pressure (200 systolic) , 
or cases with high diastolic pressure and still more important, as a 
contraindication, is a high diastolic and a relatively low systolic 
pressure. 

These baths may be prepared artificially and are resorted to in this 
country, being now installed in several watering-places. The formulae 
for making the baths are as follows in each 40 gallons of water at 
95° F.: 

Bath No. 1: sodium chloride, 4 pounds; calcium chloride, 6 ounces. 

Bath No. 2: sodium chloride, 5 pounds; calcium chloride, 8 ounces. 

Bath No. 3: sodium chloride, 6 pounds; calcium chloride, 10 ounces. 

Bath No. 4: sodium chloride, 7 pounds; calcium chloride, 10 ounces; 
sodium bicarbonate, § pound; hydrochloric acid (25 per cent.), 12 
ounces. 

Bath No. 5: sodium chloride, 9 pounds; calcium chloride, 11 ounces; 
sodium bicarbonate, 1 pound; hydrochloric acid, H pounds. 

Bath No. 6: sodium chloride, 11 pounds; calcium chloride, 12 
ounces; sodium bicarbonate, 2 pounds; hydrochloric acid, 3 pounds. 

The alkali should always be slightly in excess unless a porcelain or 
papier-mache tub is used. 

A small bottle containing the hydrochloric acid is submerged at the 
bottom of the tub, uncorked, and its contents allowed to escape into 
the water, in which effervescence at once occurs, the patient entering 
the bath at that time. The numbers of the baths simply indicate 
different strengths. Patients may never use them stronger than that 
represented by the second or third formula. Toward the close of the 
treatment the temperature may be lowered to 85° F. 

As with all other methods of treatment, the cases submitted to this 
treatment should be carefully selected, as it has its therapeutic limi- 
tations. This treatment does not necessarily exclude the use of drugs. 
A liberal vegetable diet, with small amounts of meats, is given. 

HEMORRHAGE. 

(Including Menorrhagia, Metrorrhagia, Haemoptysis, Hcematemesis, 
Intestinal Hemorrhage, Hoematuria, and Post-partum Hemorrhage.) 

Under this heading will be considered all forms of hemorrhage 
which we may endeavor to control by drugs or measures not directly 



HEMORRHAGE. 813 

surgical in their scope, with the exception of epistaxis, which has already 
been spoken of. 

Whenever a hemorrhage can be arrested by the application of a 
ligature or by compression, as in a cut of the finger or some similar 
wound, no styptic should be used. Styptics are employed for the 
double purpose of constringing the tissues and coagulating the blood, 
and, in consequence, form coagula which tend to make a septic mass 
about the wound. In their place the physician should resort to a 
compress soaked in some antiseptic liquid or filled with some disin- 
fectant powder, and if this fails to control the bleeding, then ligation 
of the bleeding vessel becomes necessary. 

Where the bleeding point cannot be reached by direct compression 
or for ligation, the use of packing and of astringents is advisable, and 
drugs which are antihemorrhagic may be used by the mouth if coagu- 
lation is delayed. 

In all forms of hemorrhage in which the flow has been sufficiently 
great to endanger the patient's life, resort should be had to hypoder- 
moclysis intravenous injection or to transfusion. (See Hypodermo- 
clysis, Intravenous Injections, and Transfusion, Part III.) 

In cases in which there is reason to believe that the hemorrhage 
continues because of diminished coagulability of the blood, particularly 
in hemorrhage in the newborn and in jaundice, a hypodermic injection 
of fresh blood serum from a healthy adult should be resorted to, to 
provide the ferment needful for coagulation. An ounce (30.0) repeated 
every day for several days is usually the amount required. (See 
Coagulose, Part III.) 

Gelatin has been employed externally to control hemorrhage, and 
has been given hypodermically to aid in the coagulation of blood in 
bleeding parts which cannot be reached directly. Lancereaux and 
Paulesco use the following formula : 

fy— Gelatini, 

Sodii chloridi aa gr. cl (10.0). 

Aquae destillatae Oij (1000 mils.). 

This mixture is sterilized by heat and 2 ounces (60 mils.) are injected 
into the tissues of the thigh or buttock. 1 This is increased to 5 ounces 
(150.0) in later injections if they are needed. Usually one or two 
doses are sufficient. A like solution may be used locally to check 
oozing. It is of little value. 

Menorrhagia is an excessive flow of menstrual blood, either excessive 
in quantity during two or three days or continuing an unusual number 
of days; while metrorrhagia is a state in which bleeding takes place 
from the uterus independently of menstruation and at any period of 
the month, or even after the menopause has occurred. 

Menorrhagia is not to be determined by the amount of the flow, 

1 The gelatin should be boiled at least an hour, as tetanus spores are often present and 
are not killed by being exposed to heat for a short time. 



814 DISEASES. 

but by whether the loss is sufficient to cause ill heath or to indicate 
disease. In some cases it is a means of relieving plethora. 

When the physician decides that something should be done to 
improve the condition of the patient, when suffering from either 
menorrhagia or metrorrhagia, it is necessary for him to find out 
whether a polypus, fibroid growth, endometritis, or other form of 
uterine disease is directly responsible for the trouble, and in the mean^ 
time to employ drugs known to act favorably upon uterine hemor- 
rhage. The most prominent of these drugs are ergot, cotarnine, and 
oil of erigeron, the first and second being the best for active bleeding, 
the second and third for oozing and for cases where there is a continual 
"show." Cotarnine hydrochlorate is given in pill or capsule in the 
dose of 1 to 2 grains four times a day. The fluidextract of ergot may 
be given in varying dose, from 10 to 60 minims (0.60-4.0), according 
to the necessities of the case, and the oil of erigeron in capsule in the 
dose of from 3 to 5 minims 0.20-0.30), or, if capsules cannot be had, the 
physician may employ the oil in an emulsion made by using syrup of 
acacia or other similar substance. Locally, sterile cotton wet with a 
sterile solution of adrenalin chloride (1:5000) may be employed. 

Where menstruation is irregular and the menorrhagia is almost 
a metrorrhagia, bromide of potassium or sodium in the dose of 10 
grains (0.60) several times a day is often very serviceable. The 
water of hamamelis in the dose of' 1 drachm (4.0) three times a day 
is sometimes useful. Cannabis indica, if an active sample is obtain- 
able, is also said to be of service, but the writer has never used it to any 
extent. Oil of cinnamon in the dose of \ drachm (2.0) is said to be 
efficacious in the slow oozing of some cases where erigeron cannot be used 
or obtained. Sometimes, where congestion of the pelvic viscera is the 
cause of the trouble, dry cups over the sacrum give relief. 

Hcemoptysis, or hemorrhage from the lung, is usually due to tuber- 
cular ulceration of a small or large bloodvessel or to mitral disease, 
and the life of the patient depends more upon the rapidity with which 
a clot naturally forms than upon the skill of the physician. 

Hemorrhage from the lung must be regarded as any other hemorrhage. 
The object of the physician is not to stimulate the heart and vasomotor 
system, thereby increasing the leakage from the bleeding vessel, but to 
lower the arterial pressure to as low a point as is safe. With this end in 
view nitroglycerin may be given hypodermically in the dose of -j-Jo" to 
xo of a grain (0.0006-0.0014) or 5 minims of amyl nitrite may be 
inhaled. If these drugs are not obtainable, chloroform may be given 
by inhalation with care, to lower blood-pressure and quiet the over- 
acting heart (See Amyl Nitrite.) 

The rule to follow is best stated as follows, if the hemorrhage has 
been severe and the patient is feeble: Place the head lower than the 
feet and apply Esmarch bandages to the limbs to keep the blood in 
the vital parts as much as possible. The use of stimulants can only 
increase the hemorrhage by increasing the pumping power of the 
heart and by dislodging the clot from the eroded bloodvessel, 



HEMORRHAGE. ' 815 

Daremburg and Yeo have employed ice or ice-cold compresses to 
the scrotum or vulva in cases of haemoptysis, and claim good results 
from this use of cold. Cold must not be used if the patient is very 
feeble. 

To allay nervous excitement many writers advise that a hypodermic 
injection of morphine should be used. Chloral and the bromides are 
often better remedies for this purpose, and should be given by the 
mouth, or, if vomiting is present, they should be given by the rectum, 
dissolved in starch-water. (See Chloral and Bromides.) 

Sometimes the patient can point directly to the spot where he thinks 
the hemorrhage exists, and under these circumstances a dry cup or a 
piece of ice placed over this point may perhaps prove useful by causing 
a reflex contraction of the deeper bloodvessels. 

Though text-books order atomized solutions to be inhaled and 
other remedies to be taken by way of the lung, in most cases these 
measures will be found impracticable, because the nervousness of the 
patient and the constant cough will not permit of inhalations to any 
extent, and even if a full breath is taken, it generally increases the 
bleeding and coughing. 

In cases where severe or repeated hemoptysis develops it may be 
unnecessary to resort to artificial pneumothorax. (See Tuberculosis.) 
After an attack of haemoptysis there is great danger in many cases 
of a traumatic pneumonia being set up by the presence of the extrava- 
sated blood. This should be combated by the use of a carefully 
regulated diet, and the reduction of any arterial excitement by small 
doses of aconite in persons not weakened by advanced disease or by 
the bleeding. Complete rest in bed is to be insisted on, and no stimulants 
allowed in food or drink unless the weakness of the patient requires 
them. 

Hematemesis. — This depends either upon some injury to the 
stomach, or, much more commonly, upon gastric ulcer, cancer, or 
cirrhosis of the liver, and is one of the easier of the so-called "internal 
hemorrhages" to treat, because by ordering the patient to swallow 
styptic drugs we can act directly upon the bleeding surface. 1 Adrenalin 
in the dose of a drachm (4.0) of 1 : 1000 solution may be given. Mor- 
phine may be used hypodermically to produce general and gastric rest 
and to aid the formation of a clot. Bandages to the extremities and 
external heat should be applied if the hemorrhage is sufficiently great 
to cause faintness. (See Gastric Ulcer.) 

Hemorrhage from the bowel is to be treated according to its point 
of origin. If in the small intestine, as in duodenal ulcer, the medi- 
cines must be used by the mouth; if it be from the colon or rectum 
or from hemorrhoids, treatment must be by way of the anus. In any 

1 Hsematemesis also ensues as a result of swallowing blood which has escaped into the 
mouth or nasopharynx, and this symptom is sometimes induced by malingerers in order 
to further their ends. These forms of hsematemesis should, of course, be separated from 
those dependent upon some lesion in the stomach itself. 



816 DISEASES. 

case rest in bed is essential, and as soon as the patient recovers from 
the hemorrhage relief from the duodenal ulcer by surgical measures 
should be resorted to. 

Hemorrhage from the bowel is best combated by hypodermic use 
of morphine, and a small ice-bag to the belly if the patient is not in 
collapse. As a matter of fact no remedy given by the mouth has any 
direct effect in intestinal bleeding. 

In melana neonatorvm or in the bleedings of hemophilia, the injec- 
tion of human serum, horse serum, coagulose, or transfusion are to be 
utilized. (See Transfusion.) 

Where the hemorrhage is dependent upon ulceration of the colon 
or rectum injections are to be resorted to. These are both styptic and 
curative, the styptic injections being particularly useful when the 
bleeding is to be stopped at once, the others where it is sought to 
remove the condition producing the trouble. 

To the first class belong alum, sulphate of copper, MonsePs solution, 
sulphate of iron, tannic acid, and cold water. In the second, we find 
nitrate of silver, the sulphates of copper and iron, and the chlorate of 
potassium. 

The alum solution used should be fairly strong, 10 grains to the 
ounce (0.60-30.0); the copper, 5 grains to the ounce (0.3-30.0); 
the Monsel salt, 10 grains to the ounce (0.60-30.0) ; or J to 1 drachm of 
MonsePs solution to each 2 ounces (2.0-4.0 : 60.0) of water. The tannic 
acid should be used in the strength of 20 grains to the ounce (1.3-30.0) 
of water and glycerin. When chlorate of potassium is used, it should 
he employed in saturated solution in small injections (25 grains to the 
ounce [1.60-30.0]); or in weaker solution if the injection be a large 
one (10 grains to the ounce [0.60-30.0]). Another useful drug, if the 
site of the hemorrhage can be reached, is adrenalin chloride in the 
proportion of 2 drachms of the ordinary 1 : 1000 solution in a half-pint 
of normal saline solution. 

These injections should be carefully given, and the success or failure 
attending the treatment of these states depends as much upon the 
technique of the operation as upon the particular medicinal substance 
employed. It should never be forgotten that an injection designed for 
local medication should be as small in bulk as circumstances will per- 
mit. Thus, in inflammation of the rectum the amount of the injected 
liquid should not be above 4 ounces (120.0) at the utmost, and prefer- 
ably 2 ounces (60.0) unless the diseased area is high up. An enema 
is given in bulk so as to cause distention and excite the bowel to move- 
ment, whereas from a medicinal injection no movement is desired. 
(See Enteroclysis, Part III.) 

Hematuria is a condition in which blood appears in the urine, and 
may be divided into two classes: that in which the blood comes from 
the kidney or bladder, and that in which it comes from the urethra. 
In the first class the blood is always well mixed with the urine, which 
is changed in color from its decomposition, and the blood is present 



HEMORRHOIDS. 817 

either during the entire act of urination or just at the end of the act. 
In those instances in which the blood is in the first part of the stream 
it arises in the urethra, is nearly pure, and not well mixed with the 

urine. 

If the hemorrhage is alarming, injections of adrenalin chloride 
(1: 5000) may be used; or astringent washes, such as 2 or 3 grains of 
alum to the ounce of water, may be injected into the bladder. It 
must be remembered, however, that alum fills the bladder with clots, 
which are not readily passed and are liable to become septic. 

Malarial infection is sometimes accompanied by hematuria or 
hemoglobinuria. The cause is obscure, and an immense amount ot 
discussion has taken place as to its proper treatment. Many physicians 
assert that the use of quinine in these cases produces disastrous results; 
others claim that the drug is most valuable. The value of quinine 
consists, undoubtedly, in its ability to prevent other attacks, rather 
than to relieve that already present or its result — the hematuria. If 
an examination of the blood shows the presence of the sestivo-autumnal 
parasite, quinine is to be freely used; but if not, it is to be avoided. 
Personally the author believes that malarial hematuria and hsemoglo- 
binuria will ultimately be found to depend upon very different causes. 
In some cases it will be found that the malarial parasite is the cause 
of the disease. In other instances it will probably be discovered 
that an entirely different organism belonging to the same general type 
of parasites is responsible for the development of this dangerous 
and much dreaded complication. (See Cinchona, Part II.) Sodium 
thiosulphate is a most useful remedy in malarial hematuria in the 
dose of 5 to 15 grains (0.3-1.0) every five hours. Many practitioners 
use as much as a drachm of thiosulphate of sodium every two hours 
until purgation takes place, give morphine and atropine hypodermically 
to relieve pain and quiet the stomach, apply cups over the kidneys, 
and give large amounts of water so as to freely flush the kidneys. 

Post-partum hemorrhage is to be controlled by the use of abdominal 
friction and kneading or grasping the dilated uterus through the 
relaxed abdominal wall ; by the use of drachm doses of the fluidextract 
of ergot or a wineglassful of the wine of ergot, or by the hypodermic 
use of 15 minims (1.0) of pituitrin or of "Ergot Aseptic"; and by irri- 
tation of the uterine wall by passing the hand, which must be abso- 
lutely aseptic, up through the vagina into the uterine cavity. In other 
cases vaginal irrigation with sterile water as hot as can be borne may be 
resorted to. 

In all forms of local hemorrhage from small vessels adrenalin 
chloride is to be thought of as a local application, or horse serum or 
coagulose given hypodermically or applied locally. 

HEMORRHOIDS. 

Hemorrhoids are vascular dilatations of capillaries, arteries, or 
venules situated outside or inside of the sphincter ani, or are com- 
52 



818 DISEASES. 

posed, in the case of what are called external piles, of tags of skin 
which are more or less vascular and become troublesome when inflamed. 

The internal pile if large, is apt to prolapse and to become strangu- 
lated by the sphincter muscle. It is covered with mucous membrane, 
and is sometimes very small or like a mulberry in shape, consisting 
of a tuft of capillaries, a loop of an arteriole, or of a venule. The 
capillary or arterial hemorrhoid is apt to be bright red, and to bleed 
profusely when touched or when scraped by hard feces. The venous 
tuft also bleeds, but not so freely, and the blood is not so bright in 
color. In cases in which the hemorrhoids "come down" — that is, 
pass out through the anus, so being in danger of becoming strangu- 
lated — the protruding mass should be washed with cold water, 
thereby at once cleansing it and reducing its congestion, and then 
gently pushed back with the fingers, which should be well oiled. 
In some cases it is advantageous to push gently into the rectum a 
cold rectal speculum, which will not only replace the piles, but also 
contract their walls and displace the blood with which they are filled. 
Care should be taken that an external hemorrhoid is not mistaken 
for an internal pile, since if an external growth is pushed through the 
sphincter it also becomes strangulated. 

The treatment of internal hemorrhoids is to a great extent identical 
with that of the external variety. A suppository may be used, made 
up as follows, if there is a tendency to slight hemorrhage: 

1^ — Acidi gallici gr xx (1.3). 

Extracti opii gr. j (0 06). 

Extract! belladonna? foliorum . . gr ij (0.12). 

Olei theobromatis q. s. — M 

Fiant suppositoriae No. x. 
S. — Use one every night. 

In place of this, distilled witch-hazel extract may be injected into 
the rectum in the quantity of 1 to 2 ounces (30.0-60.0). 

If the hemorrhage is profuse, the physician should use a speculum, 
find the bleeding point, and touch it with strong nitric acid, followed 
by the suppository named above. If this is done, the bowels should 
be confined for some days until the spot under the slough made by 
the acid can heal. 

If the prolapsed hemorrhoid is inflamed and difficult of reduction, 
the following ointment of Mathews may be ordered: 

1$ — Cocainae gr. xij (0.8). 

Iodoformi 3j (4.0). 

Extracti opii gr. xxx (2.0). 

Petrolati 5j (30.0).— M. 

S. — Use as a salve. 

Note that this prescription calls for cocaine, not cocaine hydro- 
chloride. The reason for this is that the salt of cocaine does not act 
well when mixed in an ointment. 

If the pile still refuses to be reduced, place the patient in bed and 
apply a hot compress wet with adrenalin chloride solution (1:2000). 



HEMORRHOIDS. 819 

If this fails, operation is demanded. The pile should be incised and 
the clot turned out. 

The treatment of external piles themselves consists in the main- 
tenance of the most rigid cleanliness. Immediately after each move- 
ment the parts should be thoroughly washed by means of a sponge 
dipped in cold water, or, better still, by the use of the bidet or a nozzle 
attached to a fountain syringe or to the general water-supply. (See 
Cold, Part III.) After they are thoroughly cleansed, it is well to 
bathe them with distilled extract of hamamelis. Often it is advisable 
to precede the regular daily evacuation by a rectal injection of cold 
water to soften the feces, and, more important still, to decrease con- 
gestion. If the inflammation of the external piles is very acute, the 
patient should be placed in bed and the cold injections frequently 
repeated or hot compresses applied to the anus. After this a lotion 
of lead-water and laudanum — laudanum foss (15.0) to dilute lead- 
water f5ij (60.0) may be used. 

If in association with the presence of hemorrhoids there is much 
itching the following salve may be applied : 

B — Mentholis gr. xx. 

Hydrargyri chloridi mitis gr. xxx. 

Petrolati §j (30).— M. 

S. — Apply locally. 

The injection of phenol into hemorrhoids is a dangerous practice, 
and, if employed, only 1 drop is to be used. 

In addition to these applications there are important general rules 
to be observed. 

The patient's habits should be so arranged that the daily act of 
defecation is at night before going to bed, rather than in the morning, 
as under these circumstances the rest in bed relieves congestion and 
soreness, which the maintenance of the erect posture might aggra- 
vate. Plethoric individuals should not use upholstered chairs, as the 
heat of the body relaxes the rectal tissues. A cane-seated chair is 
best, or an air-cushion with a hollow centre. The liver plays a 
most important part in relation to hemorrhoids, and, if it is congested, 
congestion of the hemorrhoidal veins is very apt to ensue. The con- 
nection between the liver and the hemorrhoidal plexus is most inti- 
mate, since this plexus is formed by the superior hemorrhoidal veins, 
which are branches of the inferior mesenteric, and the middle and 
inferior hemorrhoidal veins, which terminate in the internal iliac. 
The portal venous system is composed in part of the inferior mesen- 
teric vein, and any obstruction to venous flow in the liver at once 
results in engorgement of the hemorrhoidal plexus. 

(For the surgical treatment of piles reference must be made to 
surgical works.) 



820 DISEASES. 

HEPATITIS. 

(Acute and Chronic Hepatitis and Hepatic Abscess). 

Inflammation of the liver may be produced by many causes, such as 
injuries, cold, exposure to high temperatures (as in the tropics), syphilis, 
and the presence of any infectious disease or of parasites. It may also 
arise from alcoholism. The hepatitis of hot climates is generally sub- 
acute or chronic. The pain, swelling, and general symptoms of the 
acute form of inflammation of the liver are described thoroughly in the 
text-books on the practice of medicine. The measures commonly 
adopted for the relief of the symptoms and the disease itself are of two 
kinds: the first, medicinal; the second, dietetic. 

The patient, if the attack be acute or severe, will commonly be 
found in bed, owing to the pain and fever, but if not he must be placed 
in bed and kept in a recumbent posture. Over the surface of the 
right hypochondrium may be placed a number of small cantharidal 
blisters; or, if this is not possible, a large mustard plaster is to be 
used. Sometimes hot cloths applied over this area are equally 
efficient. At the same time, if the bowels are confined, a saline pur- 
gative, such as magnesium sulphate, should be given, and it is often 
wise to precede it several hours by small doses of calomel given in 
fractional doses. The kidneys must be kept active by spirit of nitrous 
ether and citrate of potassium, or by any one of the diuretic waters, 
such as Vichy, in moderate quantities. 

If a single hepatic abscess develops, 1 the best thing to be done is to 
expose the liver and drain it. Very frequently the inflamed organ 
will have formed a strong attachment with the peritoneal coat of the 
abdominal cavity. Any constitutional evidence of the presence of 
pus, as by night-sweats, hectic, or rigors, is a sign for immediate in- 
terference with the purulent collection. If amoebic dysentery exists, 
it must be cured as rapidly as possible by the measures generally 
employed for this purpose, but if this disease be the cause of the ab- 
scess, the proper treatment is to aspirate the pus and inject the abscess 
cavity with a solution of quinine hydrochloride containing 30 or 40 
grains (2.0-2.6). (See Ipecac and Dysentery.) Multiple hepatic 
abscess is beyond our measures of relief. 

The diet during the early and later stages of acute hepatitis should 
be limited to those articles of food which are easily digested and assim- 
ilated, and rich or greasy dishes are to be excluded. "Strong foods,' 5 
as meats of all kinds, particularly beef, pork, and mutton, are to be 
sedulously avoided. All spices in the food must be forbidden, and 
alcohol utterly tabooed. If koumyss cannot be had, the patient may 
be fed on peptonized milk or pancreatized oysters. (See Part III.) 

1 It is well to recall that many cases of hepatic abscess are now known to be due to 
dysentery, and that the diseased state of the lower bowel may result in infection of the 
liver. 



HICCOUGH. 821 

After an abscess develops the same recommendations are to be fol- 
lowed, and the diet is to be as supportive as possible, small doses of 
quinine and iron being used. 

In the treatment of the subacute or chronic hepatitis of hot climates 
no remedy compares to freshly prepared strong nitromuriatic acid, used 
both externally and internally. The acid should be a deep lemon 
color, and be mixed with water only when about to be taken in the 
dose of 3 to 4 minims (0.20-0.25) three times a day. This remedy 
is contraindicated in acute hepatitis, because it acts by stimulating 
the organ, and would only increase the severity of the acute form of 
the disease if administered at this time, Externally, it is to be used by 
mixing it with water and applying it by means of a flannel wrung out in 
the mixture, or by placing it on spongiopiline in the proportion of 
from 1 to 3 fluidrachms to the pint (4.0-12.0 : 480 mils.) of hot water 
and applying it over the liver. If 3 fluidrachms (12.0) irritate the skin 
too greatly, the smaller quantity should be employed. This applica- 
tion causes a tingling of the skin and a localized sweat. 

The hepatitis due to syphilis generally shows itself as a cirrhosis, 
and is to be treated by antisyphilitic measures. (See Syphilis.) 

If ascites develops from cirrhosis, the liquid is to be withdrawn, and 
frequent aspirations, as often as the liquid returns, have been known 
to result in apparent cure or arrest of the disease. In all forms of 
chronic hepatitis iodide of potassium is a useful remedy in the dose of 
from 5 to 20 grains (0.3-1.3) three times a day, and larger amounts 
should be used if the condition be due to syphilis. 

HICCOUGH. 

Hiccough is an affection arising from many causes, depending upon 
irritability of the nerves supplying the diaphragm as a result of gastric 
irritation, nervousness, uraemia, and as a complication of several 
exhausting diseases, such, for example, as typhoid fever. 

The mechanism of its production rests upon the sudden contraction 
or descent of the diaphragm, whereby a vacuum is formed in the chest 
into which the outside air attempts to rush, but is prevented from 
doing so by a sudden closure of the glottis, the peculiar sound of the 
hiccough being thus developed. Generally the symptom stops of 
itself, but it may become continuous and excessive. 

The remedies to be employed are used according to the cause of 
the disorder. If there be gastric or intestinal irritation, the irritating 
matter must be removed by emetics or purges, and nervous and local 
sedatives used. A drachm (4.0) of spirit of chloroform does good 
in many cases, and tincture of capsicum may be employed in other 
instances, say 5 to 10 minims (0.30-0.60) well diluted. Spirit of 
camphor, or the tincture of valerian, in the dose of 1 drachm (4.0), 
may be serviceable, and Hoffmann's anodyne is peculiarly effica- 
cious in the dose of 1 drachm (4.0) in ice-water. In the hiccough 



822 DISEASES. 

of typhoid fever nothing compares to musk, 20 grains (1.3) by the 
rectum, and, if this cannot be used, oil of amber may be given by the 
mouth in the dose of 5 to 10 minims (0.3-0.60) in capsule or emulsion, 
and followed by a drink of milk to prevent irritation of the stonach. 
Nitrite of amyl may also be inhaled. When hiccough is so persistent 
as to endanger life it must be controlled by the use of bromide of 
sodium and tincture of deodorized opium given by the bowel. (See 
article on Vomiting for directions; also see Chloretone.) 

Where external remedies are resorted to, ether thrown in a fine 
spray on the epigastrium may check an attack. 

In cases where the affection comes on after meals and is due to 
indigestion, a course of tonic treatment will often give relief. Thus nux 
vomica in pill or tincture, accompanied by some dilute mineral acid, such 
as hydrochloric or nitric, may be employed, or, if the stomach is acid — 

1$ — Sodii bicarbonatis oj (4.0). 

Tincturae nucis vomicae foj(4 0). 

Tincturae cardamomi . . . q s. ad f oiij (90.0). — M. 
S. — Teaspoonful (4.0) before each meal 

If the symptoms are due to uraemia, a hot pack may be found of 
service, unless contraindicated by advanced depression and systemic 
weakness. Even in the presence of these symptoms it may be advis- 
able to resort to this measure, protecting the patient against depression 
by a hypodermic injection of strychnine. 

INCONTINENCE OF URINE. 

Incontinence of urine may be classified either according to its forms 
or the methods of its treatment. 

Four varieties may be recognized as occurring separately, although 
all of them may occur in one case. There are cases where the bladder 
fails to hold the urine day or night, those in which the incontinence 
is only nocturnal, and those in which it occurs only upon some nervous 
start or in which the sphincter becomes relaxed from general atony. 
The first of these occurs in children, the last in adult females. A 
fourth form of incontinence depends upon paralysis arising from 
centric nervous disorder or from paralysis due to retention and con- 
sequent paralytic distention. 

Taking up the consideration of the first forms — namely, those 
occurring in children, in which the trouble is generally nocturnal — 
the complete history and the present condition of the case must be 
discovered. Many of the most obstinate cases will yield when the 
urine is made constantly clear and mild by the use of alkalies, and 
others will recover upon the removal of worms from the vagina, which 
have crawled there from the rectum, or upon circumcision of a redun- 
dant prepuce, particularly if this be tight and smegma and urine be 
found back of it in large or small quantity. The cause of the incon- 
tinence in both these conditions is reflex irritation of the bladder-walls. 



INCONTINENCE OF UR1XE. 823 

by irritation at the end of the penis or in the vagina, and the reason 
that alkalies do good is that they render the urine, when concen- 
trated and irritating, dilute, alkaline, and mild. Belladonna in these 
cases is rarely, if ever, curative, and is at most only palliative, the 
condition returning as soon as the passing off of the effects of the drug 
permits the irritation to be felt by the nerves of the bladder. After 
alkaline diuretics have been used belladonna is, however, very valuable. 
Where the urine is acid, concentrated, and dark in color the following 
prescription is always useful: 

Rf— Potassii citratis 5ij (8 0). 

Spiritus aetheris nitrosi ..... foij i (8.0). 
Aquae destillatae . . . . q. s. ad f giij (90.0). — M. 
S. — Dessertspoonful (8.0) every four hours in a tablespoonful (15.0) of water. 

As the urine becomes clear after several days a few drops of tincture 
of belladonna may be added to the mixture; but if a moderate amount 
is not sufficient, it must not be increased, as belladonna will not cure 
the condition, and may make the urine concentrated — a condition 
directly opposed to that which is wanted. 

In other instances — and these are by no means rare — the urine is 
concentrated and ammoniacal in odor. Under these circumstances 
one of .three drugs may be used with advantage, namely hexamethyl- 
enamine (urotropin or uritone) in the dose of 4 grains (0.25) in half 
a glass of water three times a day; or benzoate of ammonium, given 
in the same quantity in capsule after meals. Both of these drugs 
acidify the urine and render it antiseptic, and for obvious reasons 
are harmful if the urine is already acid. 

Sometimes these cases are dependent not so much upon vesical 
irritability as upon weakness of the spinal centres governing the 
bladder. If this be the case, the urine should first be rendered mild, 
and then remedies should be directed to the improvement of these 
parts. The following pill or the succeeding solution should be admin- 
istered : 

1$ — Arseni trioxidi ....... gr. J (0.02). 

Extracti nucis vomicae gr. ij (0.12). — M. 

Fiant pilulae No. xx. 

S. — One three times dailv after meals for a child of eight or ten vears. 

Or, 

1$ — Liquoris potassii arsenitis . tt\ xxiv (1.5) 

Tincturae nucis vomicae rri_ xxiv (1.5). 

Aquae destillatae . . . . q. s. ad f §iij (90.0). — M. 
S. — Teaspoonful (4.0) three times daily after meals for a child of eight or ten 
years. 

This mixture is so bitter as to be disagreeable, and Fowler's solution 
may often be used alone in the dose of \ to 1 minim (0.03-0.06), and 
at the same time strychnine in gelatin- or sugar-coated pill or granule 
may be given. 

It must be remembered that this last treatment is only to be employed 
in chronic cases devoid of all irritation and dependent upon atony. It 
will not do good if the urine is not previously made clear. 



824 DISEASES. 

Nothing can be more unfortunate in the treatment of these cases 
than punishment by severe scolding or whipping the child, as it never 
does good, and, the fault being beyond the child's control, the unjust 
punishment makes him sullen, or through nervousness, augmented by 
such treatment, his trouble becomes worse. In some cases it may 
be necessary, in order to cure the habit, to let the child drink diuretic 
waters for years. The patient should always be taken from bed when 
the parents retire for the night and made to evacuate the bladder. 

For the incontinence of adult females or males due to atony of the 
vesical sphincter, and which occurs on laughing or sudden movement, 
nothing compares, from a curative point of view, to drop doses of 
tincture of cantharides three or four times a day, the urine being kept 
flowing freely from the kidneys by means of alkaline diuretics. Atten- 
tion to the reaction of the urine in these cases is also of value. If it 
is acid, alkalies must be given; and if alkaline, urotropin or uritone is 
indicated. 

The treatment of the fourth form of incontinence of urine comes 
into the province of surgery. The bladder must be relieved by the 
catheter if the trouble be from retention with distention. If the dis- 
order is due to paralysis, nothing can be done except to carry out those 
general measures valuable in such cases — to maintain the urine in as 
normal a state as possible by urinary antiseptics, to catheterize fre- 
quently with an aseptic catheter, and to wash out the bladder every 
few days or hours, as the case may be, with some weak antiseptic 
fluid, such as the 1 : 10,000 solution of bichloride of mercury, or 1 : 200 
of phenol, or 1 : 1C0 of boric acid. 

INDIGESTION (GASTRIC AND INTESTINAL). 

Under the heading " Biliousness" the writer has described many of 
the conditions arising out of indigestion, and, this being the case, 
the consideration of that state known as dyspepsia or indigestion will 
only receive attention at this point in so far as its cure is concerned, 
without the relief of the symptoms produced. 

Lack of gastric digestion depends for its existence upon a great 
number of causes, and is always a symptom, not a disease. It occurs 
during the course of short or prolonged fevers from atony of the gastric 
walls and glands, from lack of secretion of the proper character, from 
hypersecretion of mucus by the mucous glands, or as the result of any 
one or all of these conditions, and, lastly, because the food is unsuitable 
to the case, or is of a kind difficult of assimilation. Sometimes it is 
due to organic changes in the abdominal viscera, as carcinoma or ulcer, 
and sometimes to acute or chronic gastritis. In each of these states 
the treatment is, of course, different, because widely separated causative 
factors must be relieved. 

The indigestion attendant upon the course of fevers can nearly 
always be avoided by a proper diet and the use of predigested food, 



INDIGESTION. 825 

such as pancreatized gruels, milk, or broths. The necessity of this 
artificial digestion is the more readily recognized when we recall the 
investigations of Hoppe-Seyler upon the quality of the gastric juice 
of a patient suffering from typhoid fever, for he found that no hydro- 
chloric acid was present. Uffelmann has also found in a similar study 
that the peptone-forming secretion of the stomach ceases entirely 
during fever. 

Where indigestion results from the presence of gastric catarrh the 
remedies applicable to such a state must be resorted to. (See Gastric 
Catarrh.) 

The studies made within recent years upon the chemical conditions 
of the gastric contents have changed the methods of treatment from 
being empirical to being rational, for it is now known that disorders of 
digestion depend on deficient or excessive acidity of the gastric juice, 
deficient formation of pepsin, stenosis of the pylorus, deficient motility 
of the gastric walls, gastroptosis and enteroptosis, and other less import- 
ant causes. Before carrying out any line of treatment the physician 
must, therefore decide, if possible, as to the underlying cause of the 
dyspepsia present in each case, and his decision may be based on well- 
described subjective symptoms by the patient, or upon this description 
aided, or it may be replaced, by examination of the stomach-contents 
after a "test-meal," or the results of £-ray examination. 

In those cases in which the dyspeptic symptoms result from imper- 
fect mastication and insalivation of food it is evident that careful rules 
about eating are to be given the patient, with the additional advice, 
which is equally good in all cases, that exact meal-hours should be 
adhered to, since irregularity in meal-hours results in imperfect digestion 
as commonly as irregularity of habit in regard to defecation results in 
constipation. If the dyspeptic symptoms are due to deficient secretion 
of gastric juice, particularly if it is found that hydrochloric acid is the 
chief deficient element, one of two plans presents itself for employ- 
ment. In many cases it will be found that the administration of 
small doses of bicarbonate of sodium, 5 to 10 grains (0.3-0.60), before 
each meal will cause a free secretion of gastric juice, particularly if it 
be given simultaneously with bitter substances which act as stimu- 
lants to the gastric mucosa. These facts are not based solely on the 
apparent improvement in the patient, but also upon careful chemical 
studies of the acidity of the gastric juice by means of the stomach- 
tube. In mild cases the taking of a glass of imported Vichy water 
(Celestins) before each meal serves to provide sufficient sodium to pro- 
duce good effects. 

The bitter substances which it is best to employ in cases of deficient 
acidity of the gastric juice are among the simple bitters, such drugs 
as quassia, cascarilla, calumba, and gentian. Among the peculiar 
bitters we have nux vomica, quinine, rhubarb, and condurango. These 
may be employed in the following form : 



826 DISEASES. 

1$ — Sodii bicarbonatis 5j (4.0). 

Tincturae nucis vomicae .... f 5j vel f oij (4.0 vel 8.0). 
Tincturse gentianae compositse q. s. ad f oiij (90.0). — M. 
S. — Teaspoonful to a dessertspoonful (4.0-8.0) before meals. 

When there is deficient gastric secretion through atrophy of the gastric 
tubules or carcinoma of the stomach, the use of hydrochloric acid is 
the better plan. Under these circumstances the following prescription 
may be ordered: 

1$ — Acidi hydro chlorici diluti .... f5j vel foiv (4.0-15.0). 
Fluidextracti condurango . . . f§j (30.0) 

Tincturae cardamomi composites q. s ad f oiij (90.0). — M. 
S. — Dessertspoonful (8.0) with or after each meal in water. 

The symptoms manifested by persons needing the treatment just 
named are variable, but generally of sufficient constancy in type to be 
fairly pathognomonic. There are generally loss of appetite, some 
impairment in general health and nutrition, and marked difficulty in 
digesting food, particularly if it be in solid form. Complaint is usually 
made of a sensation of weight after eating, without any real pain, but 
indigestion is not complete, owing to the food being finally disposed 
of in the duodenum. Often because of the delay in gastric digestion 
there is some belching of gas due to fermentation of the food in the 
presence of warmth and moisture, and without the antiseptic influ- 
ence of the gastric juice. If any food is brought up with the belching, 
it is unaltered or changed only by fermentation. Examination of 
the stomach-contents for hydrochloric acid by the phloroglucin-vanillin 
test will speedily confirm the diagnosis of absence of hydrochloric acid, 
and this confirmation should be sought for in every case. The use 
of hydrochloric acid is also of service, in that its presence in a free 
state causes the pylorus to open and permit the food to pass into the 
duodenum. When it enters the duodenum it indirectly aids digestion 
by causing the secretion into the blood of secretin, which in turn causes 
a secretion of pancreatic juice. 

In the cases of gastric indigestion depending upon hypersecretion 
of the acid of the juice a line of treatment quite at variance with that 
just discussed must be instituted. This may be divided into the 
direct and indirect forms, including the remedies which distinctly 
decrease gastric secretion and those which antagonize or overcome its 
acidity after it is poured out from the glands. In the first class we 
find both general and local nervous and glandular sedatives, and in 
the second alkaline drugs. Of the first class we have hyoscyamus, 
belladonna, and opium from the vegetable kingdom, and the bromides, 
bismuth, and nitrate of silver from the mineral. Of the second class 
we have massive doses of sodium bicarbonate taken during or after 
meals, ammonia, generally in the form of the aromatic spirit, and 
magnesia and chalk. 

As many, if not all, of the cases suffering from hyperacidity are of a 
nervous temperament, these drugs do good by quieting reflex activity 



INDIGESTION. 827 

throughout the nervous system connected with digestion, and by a 
local action on peripheral nerves, or on the glands themselves, diminish 
secretion. Of particular value for this purpose is hyoscyamus, which 
very markedly decreases gastric secretion directly and indirectly, 
and at the same time relieves gastric pain by its local sedative 
influence. 

Taking gastric ulcer as a typical instance of a condition of excessive 
secretion of hydrochloric acid, it will be found that the following pill, 
combined with an absolute milk diet or, for the first few days, allowing 
only rectal alimentation by peptonized food, will be most useful: 

li — Argenti nitratis gr. v (0.3). 

Extracti hyoscyami gr x (0 60). — M. 

Fiant pilulae No. xx. 

S — One pill one hour before taking food. 

Sometimes in place of this pill it is wise, particularly if no ulcer 
exists, to give 10 to 20 grains (0.60-1.3) of bromide of strontium one 
hour before meals, and in any case where this fails to control excessive 
secretion of acid full doses of sodium bicarbonate may be given, 20 or 
30 grains (1.3 or 2.0) or more, after each meal. The following formula 
may be used. 

1$ — Magnesias (hydrated) 3iiiss (14.0). 

Bismuthi subnitratis oiiss (10.0). 

Cretae preparatae 5iiiss (14.0). 

Sodii bicarbonatis 5iiiss (14.0). — M. 

Fiat in chartulas No. xx. 

S. — One powder stirred in water three hours after meals. 

When the bromides are given, it is best to give them in solution. If 
the stomach is very irritable and there is a tendency to vomiting, a 
powder composed as follows is often useful: 

I£ — Phenolis (cryst.) gr. xx (l^ 

Bismuthi subnitratis gr. ec (13.2). — M. 

Fiat in chartulas No. xx. 

S. — One t. i d. with or before food 

The symptoms manifested by the patients requiring this treatment 
are as follows: There is often a constant sense of gnawing or hollow- 
ness in the stomach, which is sometimes temporarily allayed by the 
taking of food. The patient is, as a rule, of a nervous temperament 
and often in a condition of nervous depression due to some exhausting 
cause. Tenderness and even pain in the epigastrium may be pro- 
duced by superficial or deep palpation, or the patient may complain 
that the pressure of her clothes is distressing. If ulcer of the stomach 
is present, all the characteristic symptoms of that lesion may be found. 
When belching occurs, there is often vomiting of sour masses or acid 
eructations or heartburn. Gastralgia more or less severe may also 
occur. Sometimes such patients are neurasthenic and need a rest- 
cure. (See Gastric Ulcer.) Duodenal ulcer or gall-stones may be 
the cause of great acidity. 



luu 



828 DISEASES. 

In cases where testing the stomach- contents shows that the excessive 
acidity is not due to hydrochloric acid, but to the acids of fermenta- 
tion, the use of the sedative drugs named is of no avail, for obvious 
reasons, and in their place sodium bicarbonate should be employed as 
a palliative, and antiseptic or antifermentative drugs, such as thymol, 
beta-naphtol, creosote, chloral, and sodium thiosulphate, as direct 
remedial agents. Lavage of the stomach should also be resorted to. 
In still other cases a mixture containing chloral and thiosulphate 
of sodium is useful because of its antiseptic influence. (See Chloral.) 
Often these cases are relieved if all fats, and butter in particular, 
are excluded from their diet-list. 

If much gas is developed and a sensation of weight in the stomach 
is felt after eating, so that the patient feels as if the food lay undigested 
in that organ, the following prescription may be used, but is contra- 
indicated if the stomach is tender on deep palpation, or, in other 
words, if acute irritation or inflammation of the stomach is present. 
It is useful in atonic states of the stomach, and it is surprising how 
much relief may be afforded by the use in such cases of these pre- 
scriptions : 

1^ — Oleoresinae capsici ... .... rqrj (0.1). 

Pepsini vel pancreatini gr xx (1.30) 

Carbonis ligni gr xl (2.60). 

Creosoti . lr^x (0.60).— M. 

Fiant pilulae No. xx. 

S. — One after eating. 

Another useful formula is: 

fy — Pulveris capsici gr. x (0 60). 

Extracti nucis vomicae gr. v (0.3). 

Taka-diastase gr. xl (2.60).— M. 

Pone in capsulas No. xx. 
S. — One with meals. 

Intestinal indigestion depends upon almost the same causes as does 
gastric dyspepsia, and is to be treated in much the same manner, 
chiefly by a careful study and regulation of the patient's diet, and by 
the use of a number of remedies calculated to aid to some extent the 
normal juices by some digestive ferment. These ferments should be 
given with the meals, or the food be "predigested" before it is taken. 

The pancreatin should be given in full dose (5 to 10 grains [0.3- 
0.60]), with bicarbonate of sodium, and alkaline mineral waters used 
if the urine is concentrated and acid. (See Biliousness.) 

Constant abdominal distress may be due to a growth or to duodenal 
ulcer which demands surgical relief. 

Sometimes when intestinal indigestion is present great flatulence 
comes on, and is an annoying symptom. Very commonly in these 
cases it will be found that the patients think they have heart disease 
because of the pain they suffer under the prsecordium. This pain is 
due to the accumulation of flatus in the small intestine, or more com- 
monly to its pressing upward at the angle where the transverse colon 



INFLUENZA. 829 

turns to go down to form the descending colon and sigmoid flexure. 
Under these circumstances the prescriptions named above will be 
found of service, or the following may be used: 

I$— Acidi nitrici diluti f Sij.vel 3iij (8 0-12.0) 

Tincturae cardamomi composite. . . fovj (180.0). — M. 
g. — Dessertspoonful (8,0) in water four times a day. 

In some persons flatulence of the large bowel is met with, and is 
often associated with atony of the muscular coats of the gut. Under 
these circumstances the following prescriptions will be found of service: 

I$— Asafcetidae gr. xl (2.6). 

Extracti nucis vomicae gr. iv (0.25). 

Extracti physostigmatis gr. iij (0.20). 

Oleoresini capsici n\x (0.60). — M. 

Fiant pilulse No. xx. 

S. — One pill three times a day, two hours after meals. 



Or, 



1$. — Tincturae belladonna? foliorum . . . f 3 iij (12.0). 
Tincturae physostigmatis .... f 3iss (6.0). 
Spiritus camphorae . . . q. s. ad fgiij (90.0).— M. 
S, — Teaspoonful (4.0) two hours after meals or whenever needed. 



Abdominal massage is a valuable aid in treating this class of cases. 
Sometimes it can be well done by directing the patient to roll slowly 
and gently a three-pound cannon-ball over the course of the colon, to 
urge on the intestinal contents and cause secretion. In other instances 
the application of a roller electrode with the rapidly interrupted cur- 
rent from a faradic apparatus is useful. 

Where intestinal indigestion results in lientery the treatment 
becomes entirely changed, except in regard to the use of a predigested 
milk diet, and efforts must be made to increase the secretion of the 
glands of the intestinal wall. Often minute doses of mercury bichlo- 
ride or podophyllin may do this, ^ to -^ grain (0.001-0.0015) of the 
first or second, respectively. More commonly, however, the mixture 
of nitric acid, given above, will be the proper treatment or perhaps 
the following if the liver is found to be torpid: 

1$ — Acidi nitrohydrochlorici (not dil.) . . f 5ss vel f oj (2.0-4.0). 
Tincturae gentianae compositae q. s. ad fovj (180.0). — M. 
S. — Dessertspoonful (8.0) every four hours or after meals, in water. 

Chloroform spirit is often valuable in some of these cases in the 
dose of 30 minims (2.0). (See Chloroform.) 



INFLUENZA. 

The disease known as influenza affects individuals so differently, 
and presents so many symptoms associated with functional disorder 
of various organs in the body, that it is almost impossible to do more 
than consider the remedies which are to be employed in the treat- 
ment of the more frequent or more immediate manifestations or 
complications. Of far greater importance than the employment of 



830 DISEASES. 

drugs must be regarded continuous rest in bed, and stimulants are in 
many cases absolutely essential. 

In those cases in which the disease is ushered in by a severe chill, 
accompanied by violent pains in the back, if the patient is seen early 
enough it may be necessary to employ remedies for the relief of the 
rigor ; with the double purpose of improving the patient's general con- 
dition and preventing internal congestion of vital organs. In the 
majority of instances, however, the patient is not seen during this 
period of the disease, but during the febrile stage, which succeeds 
that just mentioned. Under these circumstances the author does not 
believe that it is well for the physician to resort to any of the remedies 
which have been so largely used during the last few years, and which 
are known as the " antipyretics" or the derivatives of coal-tar. Although 
originally introduced for the purpose of reducing febrile tempera- 
tures, practical experience has taught that their value is very limited 
under these circumstances, and the author seldom gives antipyrme, 
phenacetin, or acetanilide with the object of reducing fever. Although 
he does not believe that these remedies are to be used for the reduction 
of temperature, he has certainly seen very marked relief follow their 
employment with the object of subduing the severe pain which occurs 
in the back, limbs, or head. Small doses are usually sufficient at least 
to reduce the suffering, if not to remove it entirely, but, as cardiac 
complications are by no means unusual, large doses are contrain- 
dicated in most persons. The author prefers to allow the patient to 
suffer from a moderate degree of pain rather than from the dangers 
incident to the administration of doses large enough to relieve it 
entirely, because in his experience these doses have to be very large 
if they are to be entirely competent as analgesics in influenza. 

A very useful recipe in these cases is a capsule containing 5 grains 
(0.3) of aspirin and 3 grains (0.20) of cinchonidine sulphate. One of 
these must be taken every three or four hours. 

If any of the coal-tar products are used either for the relief of fever 
or of pain, phenacetin and acetanilide should be chosen. Experi- 
ments made in America and in Germany on animals have proved 
that phenacetin is far less toxic in its relations to the heart than is 
antipyrine or acetanilide, and while it has in a number of instances 
seemed more apt to produce cyanosis in man than other drugs, this 
cyanosis rarely, if ever, has been associated with any other dangerous 
symptoms. Indeed, it is quite extraordinary the amount of cyanosis 
which phenacetin may produce without the respiration becoming 
greatly disordered, very much less cyanosis when caused by acetanilide 
or antipyrine being accompanied by much more alarming symptoms. A 
favorite combination with practitioners who have had a large experience 
is one of phenyl salicylate (Salol) and phenacetin. The action of the 
phenacetin in relieving the pain and in reducing the fever seems to 
point to it as a rational remedy, but the exact influence of phenyl sali- 
cylate under these circumstances is not so clear. Composed, as it is, 



INFLUENZA. 831 

of 60 per cent, of salicylic acid and 40 per cent, of phenol, it seems 
to possess a therapeutical power different from that possessed by 
either of these two constituents alone, for neither phenol nor salicylic 
acid has much power in the relief of pain when used alone, unless, as 
in the case of phenol, it is applied directly to the part affected. Per- 
haps the condition of pain in the lumbar and other muscles during 
the attack of influenza is in some unknown way associated with the 
condition which has been called "rheumatism," and in which salicylic 
acid does good in an unknown manner. Salicylic acid alone might be 
equally useful if it were dissolved in the intestine and did not irritate 
the stomach. 

On seeing a case of influenza during the first few hours of the attack 
the author resorts to those remedies which have been in use by the 
profession for many years, and, so far as he can learn, it is the custom 
of other members of the profession to give a mixture composed of 
spirit of nitrous ether and a solution of citrate of potassium in pref- 
erence to any other medicine at this time. This mixture possesses 
the advantage of increasing the action of the skin and kidneys, and 
of reducing the temperature, of quieting the circulation, and of being 
readily taken by the patient without danger of disordering the stomach 
at this time or later, which is important, as this organ is apt to become 
irritable. As a general rule, citrate of potassium is given in too small 
doses, and, unless there are reasons to the contrary, it should be 
given in the dose of 10 to 15 grains (0.60-1.0) three times a day to 
an adult. 

If the fever becomes excessive, so that there is danger of the patient 
suffering from a true hyperpyrexia, it is better to resort to cool sponging 
instead of the antipyretics just spoken of. It is a very important 
portion of this treatment to use frictions designed to bring the heated 
blood to the surface. (See Cold and Fever.) 

Hyperpyrexia in influenza does not seem to possess the same dangers 
that it does in the course of some other diseases. In the first place, as 
a general rule, the course of hyperpyrexia is very brief, and, although it 
may leave the patient weak and exhausted, the duration of the febrile 
portion of the malady does not extend beyond a few days. Clinical 
experience and physiological study have proved that it is not the tem- 
perature of 105° or 106° F. which is distinctly dangerous, but the 
continuation of this temperature for many hours which is harmful. 
Similarly, a patient ill from typhoid fever, having a temperature of 
103° for many days, is injured very much more than is a patient who 
is suffering from pneumonia, and who may have for forty-eight hours a 
temperature of 104.5° or 105° F. For these reasons a temperature 
of 104.5° or 105° F. is not particularly alarming in the condition which 
we are considering, unless there are symptoms pointing to the fact 
that the patient is being injured by an excessive temperature, as may 
be indicated by somnolence and an exceedingly dry skin as well as 
cerebral symptoms. The point to be strongly emphasized is that the 



832 DISEASES. 

mere existence of high temperature is not to be regarded as a condition 
to be overcome by the use of drugs. 

It seems to be the general consensus of opinion, both in America 
and in England, that any measures of a depleting character are dis- 
tinctly harmful in influenza, even at its earliest stages, and we would 
naturally expect that this would be the conclusion arrived at by phy- 
sicians who treat their patients rationally. Although influenza is a 
short-lived disease, there is probably no malady in which the patient 
goes so quickly into a condition of profound depression, or even 
exhaustion, as in this one. The abstraction of blood from a vein or 
by the use of wet cups for the relief of pulmonary congestion should 
not be resorted to, as it will increase the exhaustion. Before the sys- 
tem has a chance to recover from the onset of the attack it will be still 
further depressed by the therapeutic measures of the physician if he is 
unwise enough to bleed. 

As the case of influenza progresses a condition of marked depression, 
or even collapse, very frequently develops. The expression of anxiety 
on the patient's face is, to a physician who is accustomed to see it in 
other diseases, a most alarming symptom, and it is not until one has 
seen it repeatedly in influenza that he is able to give it its exact value. 
Associated with this condition, the skin is frequently covered with a 
profuse perspiration, and the pulse is apt to be very rapid, running, 
feeble, and easily compressed. At first glance the old saying, that 
''we treat the symptoms as they arise/' would seem to cover to a 
very large extent the indications which are present at this period; yet 
the author's experience, which may differ from that of some of his 
readers, is that the cardiac stimulant which we are most frequently 
accustomed to use — namely, digitalis — does not seem to take hold of 
the circulatory apparatus and to act upon it in the manner which is 
desired. It may be that the pressing symptoms make us more 
anxious and impatient as to the use of any medicament, and that we 
do not have the patience to wait and allow such a slowly acting remedy 
as digitalis to take effect. Be this as it may, the author regards 
strychnine as infinitely preferable to foxglove when these symptoms 
appear; and he has been able to prevent their appearance, or at any 
rate to modify them to a very great extent, by using strychnine in full 
doses from the first portion of the stage of depression. As a general 
rule, strychnine is given in very much smaller doses than safety requires, 
and in many instances it fails to act because the doses are too small 
to combat the profound condition of exhaustion which is present. 
In an adult there is no reason why ^ grain (0.003) may not be given 
three or four times in twenty-four hours, and in some cases it may be 
given every four hours without producing any of the symptoms of an 
overdose. Divided doses are better than a few very large ones. 

In the employment of strychnine in influenza, the author knows of 
no better illustration of the fact that in some conditions drugs should 
be given for effect rather than in customary dose, and the physician 



INFLUENZA. 833 

who is timorous in the presence of this frequent complication, de- 
pression, certainly does not lessen the patient's danger. As with all 
powerful medicaments, the action of the drug should be carefully 
watched, and at the first manifestations of muscular twitching or stiff- 
ness at the back of the neck its administration should be cut down 
or discontinued. In many instances where the collapse comes on 
suddenly the strychnine should be administered hypodermic ally and 
followed by full doses by the mouth, in order to keep up the full effect 
upon the neryous and circulatory systems. In some cases it will be 
found that the bloodvessels seem to be so atonic that the strych- 
nine is unable to produce a sufficient vascular effect to bring the 
patient out of his difficulties, and under these circumstances very 
good results follow the combination of belladonna with strychnine, 
the belladonna being a useful vasomotor stimulant under such circum- 
stances. It also should be given in full doses for effect. As the acute 
stage of depression passes off the belladonna should be stopped and 
the strychnine continued alone through convalescence. It is proper 
to point out, however, that strychnine is not suitable for the purpose 
of producing constant stimulation. It is a whip to the nervous system, 
and if used in too large a dose for too long a time the overwhipped 
system fags out. Under these circumstances it may cause an active 
delirium. Large doses should be used only for a day or two. 

Alcohol has not seemed to be of much value during the active period 
of the disease. In milk-punches and egg-nog it is, of course, useful 
during convalescence. 

When delirium comes on, it does not seem to be a symptom of very 
serious character either for immediate results or in influencing the 
prognosis as to the ultimate recovery of the case, and in cases of pneu- 
monia complicating la grippe, in which delirium is the prominent 
symptom, it is not to be regarded in the same light as similar mani- 
festations complicating ordinary pneumonia or other diseases. The 
delirium may be either talkative or muttering, but does not in the 
majority of cases require treatment, passing away with the fever and 
rarely extending into the stage of exhaustion. Medinal may be used 
as a sedative. 

^or the irritative cough steam inhalations, laden in the first stage 
with benzoin or other innocuous and sedative substances, seem par- 
ticularly useful. For the bronchitis which is often present it is gen- 
erally sufficient to administer the ordinary mixtures, containing ipecac 
and potassium citrate, in the earliest stages, and to follow them by 
chloride of ammonium and cubebs in the later stages. The author 
does not think that the compound liquorice mixture containing anti- 
mony should be given in the second stage of influenza. A complication 
too apt to occur at this time is oedema of the lung or a widespread 
bronchitis, with a profuse exudation which bids fair to drown the 
patient in his own secretions. Antimony is not only depressing to 
the circulatory and respiratory systems, but also aids very materially 
53 



834 DISEASES. 

in causing the peculiar excess of secretion which has just been spoken 
of. Hyoscyamine is in reality the drug of choice. (See Bronchitis.) 

It may be necessary to use bromides if the cough is excessive, or 
to replace them by codeine or very small doses of morphine. In many 
cases still better results will be obtained by a good preparation of 
cannabis indica, which may be pushed until it relieves the cough with- 
out in any way endangering the patient's life — a safety which cannot 
be obtained by the employment of any other of the drugs named. 

If sleeplessness is so pressing a symptom as to require attention, the 
bromides may be given, but it will be generally found that the insomnia 
comes after the attack rather than during it, or in any event it will not 
require attention until the patient is convalescent. Under these circum- 
stances barbital, medinal or barbital sodium, or even sulphonal (sul- 
phonmethane) may be administered, care being taken in the case of 
sulphonal (sulphonmethane) that it is administered in a powdered 
form or dissolved in hot water and given four or five hours before the 
time at which sleep is desired. 

For the vertigo and dizziness, which are sometimes bitterly com- 
plained of by the patient either during or after the attack, moderate 
doses of bromide of sodium with ergot or cannabis indica have seemed 
particularly valuable, probably because they exercise some effect 
upon the bloodvessels of the brain or its membranes or perhaps upon 
the bloodvessels of the ear. Certain it is that in those cases of tin- 
nitus not associated with organic change in the aural canals bro- 
mides and ergot do more toward relieving them than any other medi- 
cation. 

In the constipation which is sometimes present in the early stages 
of influenza it is generally advisable to administer either castor oil 
or in other cases a bottle of the citrate of magnesium. A full purgative 
effect of any of these salines seems to lessen the fever when the bowels 
are unloaded. Care should be taken that the dose of the purgative 
is not excessively large, as it will weaken the patient. For the con- 
stipation following the attack probably no drug is so efficient as 
cascara sagrada, combined perhaps with aloin. (See Constipation.) 
If diarrhoea supplants the constipation, the ordinary astringents, 
such as aromatic sulphuric acid and hsematoxylon, will be found suffi- 
ciently active. (See Diarrhoea.) 

INSOMNIA. 

Insomnia is a condition complicating many diseases, and arises 
from such a host of causes that the physician may not be able to dis- 
cover them for some days after the patient is first seen. As a general 
rule, a patient consulting a physician with this symptom expects a 
prescription to be given at once and the cause of the insomnia found 
out afterward. Under these circumstances the physician may employ 
several drugs according to the information that he has concerning 
the patient's state. 



INSOMNIA. 835 

During the last few years a large number of remedies have been 
introduced as hypnotics, such as medinal, barbital, paraldehyde, 
chloralamide, sulphonal, trional, and others. Of these the best, from 
every point of view, are medinal, barbital, sulphonal, and trional. 
The dose of barbital and medinal is 5 to 15 grains (0.3-0.6), best 
given in capsule, and of sulphonal and trional the dose is 10 to 20 
grains (0.60-1.3) in powder, but as they are large in bulk, they 
should be used in a prescription made up as follows: 

R— Sulphonal (sulphonmethani) .... gr. xxx (2.0). 

Syrupi f5ij (8.0). 

Mucilaginis acaciae foij (8.0). 

Aquae destillatae q. s. ad f § j (30.0).— M. 

S. — From half to all of this at one dose, as may be needed. 

In other instances sulphonal may be dissolved in very hot water or 
milk, and the solution swallowed before it cools sufficiently to permit 
precipitation. 

One of the most common remedies is hydrated chloral given in the 
following manner: 

3— Chlorali hydrati 5"j (12.0). 

Syrupi f oiv (16.0). 

Aquae cinnamomi . . . . q. s. ad f oiij (90.0). — M. 
S. — Dessertspoonful (8.0) at night 

Or, 

1$ — Butyl-chlorali hydrati oj (4.0). 

Fiant pilulse No. xii. 

S. — One, two, or three pills at night, as needed. 

Where, for any reason, as the presence of a weak heart, chloral is 
contraindicated, resort may be had to the bromide of strontium or 
sodium, and if the patient is a woman these drugs should always be 
accompanied by a small dose of arsenic, generally in the form of 
Fowler's solution, 1 to 3 minims (0.06-0.20) three times a day in 
order to avoid the possibility of the production of acne. The fol- 
lowing prescription is useful: 

I$— Strontii bromidi . ._ 5ij vel §ss (8.0-16.0). 

Liquoris potassii arsenitis f oss (2.0). 

Aquae cinnamomi . . . . q. s. ad f §vj (180.0). — M. 
S. — One or two dessertspoonfuls (8.0-15.0) at night. 

In many cases larger amounts of the bromide will be needed. 

Where the sleeplessness is due to pain, chloral is of little value and 
bromides are worthless. Under these circumstances by resorting to 
what is known as the "crossed action of drugs," we can often obtain 
a very good effect. Thus morphine and chloral both act on the brain 
to produce sleep, or, in other words, their action is here crossed, for 
one relieves pain and the other does not; one kills by failure of the 
heart in overdose, the other by respiratory failure; as a consequence 
large doses of neither can be given alone. The following is therefore 
a useful combination, either where one drug fails or when danger- 



836 DISEASES. 

ously large doses of either alone have to be used to obtain the desired 
result: 

1$ — Morphinae sulphatis . . . . . . gr. ij vel iv (0.12-0.25). 

Chlorali hydrati 5ij (8.0). 

Syrupi . f§ij (60.0). 

Aquae q. s. ad f §iv (120.0).— M. 

S. — Dessertspoonful (8.0) at night. 

In cases where insomnia is due to mania hyoscine is very useful, 
given in the dose of y-J-g- to -§-$ grain (0.0006-0.0007) by the mouth 
or ywo g ra i n (0.0006) by the hypodermic needle. Owing to its taste- 
lessness the powder may be put on the tongue, and it is best to order a 
little sugar of milk or white sugar (1 grain) to be added to each dose of 
hyoscine, in order to give it bulk. 

When insomnia follows mental effort, avoidance of all cerebral 
activity should be insisted upon during the evening, and if the feet are 
cold on going to bed, sleep should be induced by relieving the cerebral 
congestion by a hot foot-bath or the use of a hot-water bag at the feet 
while cold is applied to the head. In other instances a general hot 
bath, during which an ice-bag is applied to the head, will produce 
sleep when drugs fail; and it is to be remembered that in the insomnia 
of convalescence and neurasthenia hydrotherapeutic measures are to 
be used to the exclusion of drugs (see Cold and Heat), for the former 
cure the condition, while the latter only palliate, and may produce a 
drug-habit. 

Not infrequently patients convalescing from prolonged illness suffer 
from drowsiness during the day and wakefulness at night because the 
circulation is feeble and fails to supply the brain with blood while the 
body is erect, but does so very well when recumbent. Hydrotherapy 
to improve vascular tone and the use of a pill of nux vomica and 
arsenic, or nux vomica and phosphorus, is useful in these cases. 

In ordinary nervous insomnia or that due to heart disease chloretone 
often acts very efficaciously in the dose of 5 to 10 grains (0.3-0.6) ; 
in tablets or capsules of 3 to 5 grains (0.20-0.30) each. 

Chloralamide (C ' hloralformamidum) sometimes does good in the dose 
of 15 to 60 grains (1.0-4.0), dissolved in wine or given in capsule. 
Paraldehyde is given in the dose of 20 to 60 minims (1.3-4.0). As it 
is disagreeable in odor and taste, it must be given in capsule. It is 
very apt to disorder the stomach, but it acts promptly. 

In the treatment of insomnia it should be remembered that if pos- 
sible those drugs should be used which will quiet the part of the brain 
which is most active. Thus if the patient is restless, bromides and 
chloral should be used as motor depressants. If sensation is acute, 
bromides and the hot pack may be used as sensory quietants. 

In some cases horseback exercise taken late in the afternoon does 
good, particularly if the patient follows a sedentary life. Care must 
be taken to avoid excessive fatigue. Many persons who are usually 
sleepless will obtain a refreshing slumber by taking a very light and 
easily digested meal just before retiring for the night or by eating a 



INTERMITTENT AND REMITTENT FEVER. 837 

cracker or drinking a glass of milk when they awake during the 
night. 

In some instance sleeplessness arises from acidity of the stomach, 
and is put aside by the use of bicarbonate of sodium. 

INTERMITTENT AND REMITTENT FEVERS. 

It having been proved that malarial fever is always the result of the 
bite of a mosquito, the disease is to be prevented by removing mosquito- 
breeding pools and by protecting the skin. It is also important to 
prevent mosquitoes from biting a patient with malaria, as by this 
means the infection is spread. Such patients should sleep under a 
netting. 

The diagnosis of "malaria" followed by the use of quinine has in 
the past been one of the abuses of medical practice. At present, even 
allowing for the unusual manifestations of this infection, the use of 
the microscope makes the diagnosis and the therapeutics sure. The 
diagnosis is, of course, clinical as well as microscopic and the special 
parasite in a given case is indicated by the symptoms as well as by the 
microscope. 

The Tertian Parasite. — The tertian parasite clinically produces a 
sharp temperature rise introduced by a chill. This is followed by a 
sweat and a fall to normal or subnormal. The whole attack is usually 
over in eight hours and recurs, as the name of the parasite indicates, 
every third day. Microscopically this parasite is the largest of the 
three plasmodia. The plasmodium vivax is found in the peripheral blood 
in all its stages from the small rings to the adult sporulating organism. 
The red cells which are infected are strongly stippled and are large 
and swollen in appearance. The spores when set free are larger than 
the spores of the malignant form. The tertian parasite is always 
the most prevalent in the temperate zone. 

The Quartan Parasite. — The quartan parasite clinically produces 
short, sharp attacks like the tertian ; except, as its name indicates, the 
attacks occur every fourth day. The disease is usually mild in its 
manifestations but is more resistant to quinine and more prone to 
relapse than the ordinary tertian or malignant sestivo-autumnal parasite. 
Microscopically it does not enlarge the corpuscles as does the tertian 
and the intracorpuscular movements of the parasite are not so marked. 

The Mstiw-autumnal or Malignant Tertian Parasite. — Clinically the 
rise of temperature may be as prompt but there is then a slight abor- 
tive fall followed by a rise so that the attack lasts eighteen to twenty 
hours instead of eight. The rigors are, as a rule, less marked than in 
ordinary tertian. The patient is manifestly severely ill (see below). 

Microscopically this organism {Plasmodium falciparum) is found 
in the peripheral blood only during the young or ring stage. The red 
cells which are involved are shrunken, not swollen, and have a metallic 
appearance and they are not stippled. Sporulation is not often seen 



838 DISEASES. 

as it does not take place in the peripheral blood but in the capillaries 
of the viscera. Repeated examinations may therefore be necessary to 
find the parasite. 

Finally the examination of the white cells will give much valuable 
collateral diagnostic evidence. Thomson states that malaria is the 
only disease in which the leukocytes of the peripheral blood contain 
dark brown pigment granules and this is particularly true of the large 
mononuclear cells. There is a relative increase in the mononuclear 
cells particularly between the paroxysms, but there is a general leuko- 
penia except when the comatose type of malignant infection is present, 
when there may be a leucocytosis of 100,000 (Thomson). A poly- 
morphonuclear leucocytosis indicates no malaria unless there is an 
inflammatory complication. (For the changes produced in these 
parasites by quinine see Cinchona in Part II.) 

In all forms of intermittent fever, whether the attacks are quotidian, 
tertian, or quartan, the best remedy for their prevention is quinine, 
which if given by the mouth should be administered about two or three 
hours before the attack is expected, so as to be absorbed and be active 
when sporulation takes place. This precaution is often overlooked, 
and the dose ordered at the time of the expected attack, with failure 
as a result. Not only should sufficient time elapse for absorption, but 
the fact should be remembered that the chill often begins an hour 
earlier each day, and will be in full sway before the quinine can stop it 
if the drug be not administered at the proper time. 

Two methods of giving quinine in malaria have been employed. In 
one it is given just before an expected paroxysm, to prevent it by 
destroying the parasite at the time of maturity. In the other plan the 
drug has been administered in the sweating stage, not because it will 
have any valuable influence on that particular paroxysm — which is 
nearly over — but in order that it may destroy the young spores which 
are floating free in the blood-stream and about to attack corpuscles, 
in which they will mature. Undoubtedly if the quinine is given at the 
proper time before an attack it tends not only to prevent the oncoming 
paroxy sm, but also future ones by its influence upon the mature and 
immature parasites. If, therefore, the patient is seen before the attack, 
he should receive quinine to prevent or modify it. If seen after an 
attack is well advanced, he should receive the drug to prevent the next 
attack by destroying the crop of parasites set free in the blood during 
the paroxysm just passed. 

In other words, quinine should be given freely daily until the infec- 
tion is eradicated in order that any double infection may be overcome, 
that no immune parasites may be developed, and that the sexual form 
of the parasite, which does not produce a paroxysm but infects mosqui- 
toes which spread the disease, may not develop. The best method if 
the quinine is given orally is to administer 10 grains (0.65) t. i. d., for 
three weeks, even if the patient seems well after a few days. (See 
also intravenous use under Cinchona.) 



INTERMITTENT AND REMITTENT FEVERS. 



839 



Experience has proved that quinine never acts as favorably if con- 
stipation is present as when the bowels are lax, and hepatic activity 
seems particularly necessary for its full effect. To obtain the full 
influence of the drug, it should be preceded, by some four or five 
hours, by 1 grain (0.06) of calomel every fifteen minutes until 5 grains 
(0.3) are taken, or by a dose of podophyllin amounting to T V to | 
grain (0.006-0.008). If the podophyllin is used, a longer time should 
be allowed, because of the slow action of this purgative, and if the 



Fig. 136. 



October 




Typhoid fever convalescence complicated by malarial tertain parasite in blood, 
quinine. First rise in temperature due to typhoid orchitis. 



Cured by 



patient has been rendered unusually insensitive to purgatives, larger 
doses of both the remedies named must be used; particularly is this 
true in the hot climates, where 5 to 20 grains (0.3-1.3) of calomel are 
often used and really needed. 

The dose of quinine varies with the exigencies of the case, which in 
turn generally depend upon the region in which the patient lives or 
has lived. If the patient remains in bed, smaller doses are needed 



840 DISEASES. 

than if he remains up and about; 10 to 15 grains (0.6-1.0) in one 
dose are often sufficient in the eastern and northern States, but as 
much as 20 to 45 (1.3-3.0) or even 60 grains (4.0) may be required in 
the southern and southwestern parts of the United States and else- 
where. Unless the condition is very grave, however, these amounts are 
best given in divided doses every few hours. The same dose is to be 
repeated daily until no parasites can be found in the blood, and if the 
attacks do not recur, it is wise to repeat the dose of quinine every week 
for several weeks to avoid relapse. Medication by the mouth may 
fail because of slow absorption or partial destruction of the drug in the 
liver. It is important to remember that while small doses may seem 
to cure the patient by preventing sporulation and the development of 
chills and fever, they may not destroy those parasites which hide in the 
spleen and bone-marrow where they gradually become immune to qui- 
nine. When the drug is stopped they return to the blood-stream, spcr- 
ulate, and may be difficult to kill unless they are attacked by hypo- 
dermic or intravenous doses or by the use of salvarsan. In this con- 
nection the conclusions of Iversen and Tuschinski are of interest: 

(1) An intravenous injection of 0.5 gramme of salvarsan exerts a 
specific effect on all forms of malaria. 

(2) The tertian parasites usually disappear from the circulation 
within forty-eight hours, but these writers cannot say definitely that a 
recurrence cannot take place. 

(3) In quartan forms salvarsan has only a slight and temporary effect. 

(4) In malignant tertian forms, even when doses up to 0.8 gramme 
are used, salvarsan only causes a temporary disappearance of the ring 
parasites from the circulation. The crescents are not affected. 

(5) In some cases of malignant tertian malaria salvarsan produces a 
temporary improvement, followed by an aggravation of all the symp- 
toms with a considerable increase in the number of the parasites 
present. 

When an immediate and certain effect is essential, quinine should be 
given intravenously. (For the best salts of quinine for intravenous 
use, see article on Cinchona.) 

Having considered the prophylaxis of a chill, let us turn to the 
treatment of the attack itself. It must be remembered that the greater 
part of the harmful effect of the malarial poison is exerted at this 
time by the internal congestions and engorgement of the abdominal 
and thoracic organs. The physician should therefore try to prevent 
so far as possible too great a rigor; and if stasis results from the chill, 
overcome it, not by depletants, but by stimulants, such as strychnine 
or digitalis, which will drive out the blood from the congested area. 

If a full meal has just been eaten, the stomach should be emptied 
by an emetic dose of ipecac, 2 drachms (8.0) of the powdered drug to 
an adult, or by | grain (0.006) of apomorphine. It is almost useless 
to give quinine at this time, as absorption from the stomach and sub- 



INTERMITTENT AND REMITTENT FEVERS. 841 

cutaneous tissues is almost entirely absent. Alcoholic stimulants 
are not to be employed, as clinical experience seems to indicate that 
they do not act favorably. 

If the chill is severe enough to endanger the patient's life, measures 
must be used to control it. Chloroform may be inhaled, and immedi- 
ately preceded by laudanum by the bowel or mouth. If the laudanum 
is given by the mouth, a little ether or chloroform may be added to 
the dose of the opiate. The opium may be used hypodermically in 
the form of morphine in the dose of ^ grain (0.01) combined with g- 1 ^ 
grain (0.001) of atropine. 

In the fevered stage little can be done except to give the patient 
comfort by cool drinks and cool sponging, or, if the fever becomes 
excessive, by the use of ice-cold sponging with active friction. These 
measures have seldom to be used, as the fever is generally too fugitive 
to need such treatment. 

The sweating stage needs no particular treatment unless exhaustion 
is caused by it, when stimulants may be cautiously used as needed, 
and large draughts of water at ordinary temperatures swallowed. 

Pernicious Malarial Fever. 

This is one of the most acute and dangerous infections if it be fully 
developed, and requires the greatest activity and skill on the part of 
the physician, who may be called upon to treat a large number of 
widely varying symptoms, all of a pressing nature, at one and the 
same time. The chief indication is for the use of quinine in its most 
soluble forms, in solution and in large doses, which may be given 
intramuscularly or intravenously. (See Cinchona.) 

As a rule, the use of the drug by the mouth is futile because the 
state of the stomach is such that absorption will not take place in time 
to be of any service. The intravenous use of the drug is therefore 
advisable. Given in this manner, doses ranging from 10 to 15 grains 
(0.6-1.0) may be used at each dose with safety. If more than this is 
given intravenously, the dose must be given very slowly, and prefer- 
ably divided into several smaller doses lest cardiac depression ensue. 
If the attack be of the hsematuric or hsemogiobinuric type, quinine is 
to be used with the greatest caution, and not at all unless the malarial 
organism can be found in the blood. (See Cinchona.) The patient 
may be treated by the use of 60-grain (4.0) doses of thiosulphate of 
sodium every two or three hours until the bowels are moved freely in 
such cases. Copious draughts of pure water, with or without lemon- 
juice added, are to be given to flush the kidneys, and if necessary 
morphine and atropine are to be given hypodermically to control the 
retching and vomiting. 



842 DISEASES. 

Remittent Fever. 

This is sometimes called bilious fever by reason of the violent bilious 
vomiting and jaundice which often accompany it. It separates itself 
from intermittent fever by the fact that the patient's condition, chiefly 
as regards temperature, does not have normal intervals, but has periods 
of only temporary improvement, or in other words, the disease remits. 

For the proper treatment of this fever, three facts must be borne 
in mind: (1) It is more dangerous than intermittent fever. (2) The 
patient, not having periods for complete or partial recovery, rapidly 
loses strength. The safety of the patient depends upon the use of 
large doses of quinine to cut short the pyrexial stage, the doses used 
being from 20 to 30 grains (1.3-2.0) a day or 5 grains (0.3) every 
four hours, preceded by a good-sized purgative dose of calomel, say 
3 or 4 grains (0.2-0.25). If vomiting is too violent to permit of the 
retention of the quinine, it must be used intravenously, the stomach 
and intestines being first swept out by the use of divided doses of 
Seidlitz powder or citrate or sulphate of magnesium. (See Cin- 
chona.) If purgatives are used, they should precede the quinine by 
sixty minutes, as otherwise the latter drug is swept out in the bowels, 
where it is rendered useless by reason of its precipitation by the alka- 
line juices there present. If pyrexia is excessive, relief must be sought 
in the use of cool sponging with friction. Cure is much facilitated by 
absolute rest in bed. 

A good treatment of the vomiting is the use of small doses of mor- 
phine, or 3- to 5-minim (0.2-0.3) doses of chloroform, in compound 
tincture of lavender and water. Aconite may also be used if the 
patient is strong enough. (See Vomiting.) 

If the belly is tender, a turpentine stupe should be applied. (See 
Turpentine.) 

If hematuria appears and the malarial parasite is found in the blood, 
quinine must be used, but it should be remembered that quinine in 
some cases increases the hematuria. (See Cinchona and Collective 
Investigation by author in Therapeutic Gazette, July, 1892.) 

The treatment of convalescence consists in the use of tonics, such as 
quassia, calumba, gentian, Huxham's tincture, arsenic, and purgatives 
when needed, with attention to the kidneys, the potassium salts being 
employed to keep these organs active. 



IRITIS. 

Iritis, or inflammation of the iris, as usually encountered, is caused 
by syphilis, gonorrhoea, tuberculosis, local septic areas, and certain 
diseases of nutrition, for example, gout and diabetes. It may also be 
traumatic. It is practically never observed in acute rheumatic fever, 
but often arises in the subjects of so-called chronic rheumatism and 



IRITIS. 843 

muscular rheumatism, the iritis and the general disease in all probability 
being due to the same as yet unknown cause. Many types of iritis 
iridocyclitis, or uveitis are due to bacterial infections arising from local 
septic areas, for example, pyorrhoea alveolaris, accessory sinus disease, 
tonsillitis, and intestinal putrefaction, the inflammation being called 
into existence by the micro-organisms themselves or their toxic products. 
Metastatic iritis occurs in pyemia and in a number of infectious dis- 
eases, for instance, recurrent fever, variola, influenza, etc. The most 
marked symptoms of ordinary iritis are severe brow pain; fine ciliary 
injection; discoloration of the iris and immobility of the pupil, due to 
the formation of adhesions between the iris and the capsule of the lens, 
the so-called posterior synechia. The most important local remedy 
is atropine (4 grains to 1 fluidounce), one drop to be used every four 
hours, according to circumstances. If for any reason this remedy is 
not tolerated, duboisin, scopolamin, or daturin (2 grains to 1 fluidounce) 
may be substituted. Great care must be taken not to mistake iritis for 
conjunctivitis, on the one hand, and glaucoma for iritis, on the other; 
delayed use of atropine and the employment of astringents on account 
of the former error, or the instillation of atropine because of the latter, 
would constitute a serious therapeutic blunder. 

Pain may be relieved by leeches to the temple and the use of dry 
heat externally (cotton batting heated over a register will suffice), 
or hot compresses composed of lint soaked in water at a temperature of 
110° F., frequently changed. In traumatic iritis iced compresses are of 
service. Usually they are not satisfactory in those forms of iritis which 
depend upon constitutional disturbance. In uveitis (sometimes called 
serous iritis), or that disease in which there is a hypersecretion of the 
aqueous humor, which becomes turbid and a precipitate of dark spots is 
deposited on the membrane of Descemet, there must be constant ob- 
servation of the effect of the atropine, inasmuch as there is frequently 
a tendency to increase of the intraocular tension. Should this occur, 
paracentesis of the cornea may be required. Free sweating, either 
with the aid of hypodermic injections of pilocarpin or by means of an 
ordinary electric cabinet, is efficacious, as, indeed, it is in many forms 
of iritis. 

Uveitis depends upon the same causes which are active in the produc- 
tion of ordinary iritis, and its chronic varieties are often due to tuber- 
culosis, and in these circumstances injections of tuberculin are to be 
commended. 

In certain forms of iritis, particularly the stubborn and relapsing 
varieties, subconjunctival injections have been highly commended, for 
example, cyanid of mercury (1 ; 5000), a few drops of a 1 per cent, solu- 
tion of acoin being added to the injection in order to mitigate the pain. 
From 10 to 15 minims of the cyanid solution may be injected subcon- 
junctivally. Similar injections of physiological salt solution are equally 
efficacious and preferable because they cause less pain. The relief of 
pain in all forms of iritis constitutes an important part of the treat- 



844 DISEASES 

ment; hypodermic injection of morphine is perfectly justifiable in emer- 
gencies, but must not be repeated too frequently. Hyoscine, y^ to 
yor of a grain, at night, is a valuable remedy. Locally, dionin (5 per 
cent, solution) is of distinct value; it stimulates lymphagogue activity 
and causes somewhat prolonged local analgesia. It may be combined 
with atropine in the usual strength and reinforced with a 2 per cent, 
solution of holocain. 

In all forms of iritis it is important to determine the presence of the 
constitutional disease, or the area of local sepsis which is the source of 
the disease. Therefore a Wassermann test and a tuberculin test should 
be instituted. Teeth, tonsils, accessory sinuses, etc., should be exam- 
ined and pathological conditions corrected and search made for septic 
foci by .T-ray examination of the teeth and sinuses. 

If the cause of the iritic inflammation is syphilis, mercury should be 
pushed to the point of tolerance, but it is not necessary to salivate 
the patient. Any form of mercury usually employed in secondary 
syphilis may be used — calomel, blue mass, or protiodide of mercury; 
very efficacious are inunctions of unguentum hydrargyrum, 1 drachm 
daily preceded by a hot pack, as also are hypodermics of salicylate 
of mercury. In all types of syphilitic iritis salvarsan and neosalvarsan 
yield admirable results, and under their influence the lesions disappear 
with surprising promptness. During the intervals between the injec- 
tions mercury and iodide of potassium may be administered. Mercury 
is a valuable remedy in non-syphilitic iritis, acting as a powerful altera- 
tive. Potassium iodide, either alone or in combination with bichloride 
of mercury, is frequently employed. In so-called rheumatic iritis, or 
that form of the disease which appears in the subjects of chronic rheu- 
matism, muscular rheumatism and polyarthritis, salicylate of sodium 
should be administered in full doses, or aspirin may be employed in 
its place. Potassium iodide is a proper remedy in gonorrheal iritis, 
and this form of the disease often responds satisfactorily to profuse 
diaphoresis. Excellent results follow the use of Neisser's bacterin. 
Naturally, such regulation of diet and such remedial agents as are 
indicated by the various other causes of iritis, for example, gout, 
diabetes, and the like, must receive full consideration, if examination 
has proved these factors to be etiologically active. During the course of 
iritis the condition of the alimentary canal should receive strict atten- 
tion, and often a course of saline laxatives is followed by excellent 
results. In certain forms of iritis, bacterial in origin, especially if the 
micro-organism can be isolated from an area of local sepsis which is 
furnishing the infecting agent, autogenous vaccines have achieved 
admirable results. In chronic iritis, and in some forms of relapsing 
iritis, iridectomy is required to reopen the angle of the anterior chamber 
which has been closed by inflammatory exudations, in order to prevent 
secondary glaucoma. 



KERATITIS. 845 



KERATITIS. 



Keratitis is the name applied to the various types of inflammation 
of the cornea. If this inflammation is associated with a breach in 
the continuity of the corneal surface, it is termed corneal nicer, and 
photophobia, or dread of light; blepharospasm, or spasmodic con- 
traction of the orbicularis muscle; congestion of the bloodvessels; and 
pain are constant symptoms. 

Interstitial Keratitis. 

Interstitial keratitis is that form of chronic diffuse inflammation of 
the cornea characterized by ciliary congestion and a ground-glass 
appearance of this membrane, most common between the ages of five 
and fifteen years, and in the majority of cases the result of inherited 
syphilis. In from 2 to 10 per cent, of the cases acquired syphilis is 
the etiologic factor. No local measure is sufficient, antisyphilitic treat- 
ment being of paramount importance. Salvarsan and neosalvarsan 
are valuable in syphilitic cases. During the height of the ciliary con- 
gestion warm antiseptic lotions and atropine are indicated, the latter 
especially to prevent the tendency to iritis. Severe pain may be allevi- 
ated by the use of a leech to the temple if the subject be of sufficient 
age to justify the employment of local bleeding. Dionin is of value. 
Exactly similar forms of keratitis are caused by rhachitis, tuberculosis, 
myxcedema and depressed nutrition. In addition to the local measures 
already described, the appropriate constitutional remedies are required, 
particularly iron, arsenic, cod-liver oil, and the iodides. Suitable 
dietetic and general hygienic measures are important, and in tuber- 
culous cases injections of tuberculin are efficacious. Patients with 
interstitial keratitis should be subjected to Wassermann and tuberculin 
tests. 

Various other types of keratitis are described as the result of con- 
stitutional disturbances, such as gout (Hutchinson), malaria (Kipp, 
van Milligen), or any condition of the system associated with great 
exhaustion, such as irregularities in the menstrual function, certain 
forms of pulmonary disorders (true herpes of the cornea, Horner). 
The local management of these cases does not differ from that which 
has been described. The coexisting constitutional disturbances must 
be combated with suitable remedies. Parenchymatous keratitis appar- 
ently is due in some cases to defective intestinal function and auto- 
intoxication. Some forms are the result of focal sepsis in the buccal 
mucous membrane and some types result from traumatism. 

Phlyctenular Keratitis. 

Phlyctenular keratitis appears in the form of small, blister-like 
bodies, sometimes single, sometimes multiple, frequently situated 



846 DISEASES. 

directly at the corneoscleral margin, which become yellow, break 
down, and leave an open ulcer (phlyctenular ulcer), to which runs a 
leash of injected bloodvessels. The disease is common in children, 
often follows in the wake of the exanthemata, and is so frequently 
associated with a so-called strumous diathesis that it was formerly 
called strumous ophthalmia. The clinical association between this 
disease and eczema of the face and scalp is an intimate one. In the 
majority of cases there is coexisting nasal disease, especially adenoid 
vegetations, which is responsible for the frequent relapses of the dis- 
order, even if it does not cause it. Congestion may be relieved by 
frequent irrigation with a warm boric-acid solution. Pain and irri- 
tation call for the use .of atropine drops (4 grains to the ounce [0.25- 
30.0]), which should be continued until the ulcer is covered with regener- 
ated epithelium, when the process of cicatrization may be hastened by 
the insertion daily into the conjunctival sac of a small quantity of 
yellow oxide of mercury salve or dusting it with finely powdered calomel, 
providing the patient is not taking at the same time any form of iodine. 
During the whole treatment the eyes should be protected by dark 
glasses and the subject permitted to go out into the open air. All 
local treatment will prove unsatisfactory unless associated with strict 
hygiene, carefully regulated diet, and constitutional measures — tonics 
and alteratives — and treatment of the nasopharyngeal lesions. 

The evidence is daily increasing that phlyctenular keratitis is closely 
connected with tuberculosis and probably caused by it. Hence its 
subjects, especially in dispensary service, should be treated like other 
cases of tuberculosis, viz., after the patient is instructed as to general 
living, proper food, etc., he is visited by one of the workers in the 
social service of the hospital, and is shown how to live and helped to 
carry out all directions. 

If the photophobia becomes distressing in spite of the other treat- 
ment, it has been suggested that this may be relieved by the use of 
cocaine, a practice that by no means commends itself in corneal ulcera- 
tion, in spite of the temporary relief from local anaesthesia. Holocain 
(2 per cent.) may be employed. Relief of this symptom in many in- 
stances follows the use of a douche of cold water on the closed eyelids, 
or by touching with blue-stone the ulcerated fissure at the external 
commissural angle, which is commonly an exciting cause of the spas- 
modic closure of the lids. 

Ulcerative Keratitis. 

Ulcerative keratitis, or ulcers of the cornea, may be primary in 
origin — that is, the disease begins in the cornea — and may be caused by 
phlyctenular disease, injury, abscess, depressed nutrition, etc.; or may 
be secondary, and result as the sequel of severe inflammations of the 
conjunctiva: for example, purulent, diphtheritic, or granular con- 
junctivitis. There are numerous varieties of corneal ulcers, but three 



KERATITIS. 847 

groups only will be mentioned: simple ulcers, which form a small, 
superficial gray lesion, and are not accompanied by much vascularity 
or dread of light; purulent or deep ulcers, in which the open lesion is 
of yellowish color and is surrounded by hazy cornea; and infecting or 
sloughing ulcers (purulent keratitis), in which the ulcer assumes a 
serpiginous or creeping form, and there is usually a deposition of pus 
in the bottom of the anterior chamber (hypopyon-keratitis). Typical 
serpiginous ulcer of the cornea with hypopyon is frequently caused by 
the Frankel-Weichselbaum capsulated diplococcus; that ulcers not 
typically serpiginous may originate from a staphylococcus, strepto- 
coccus, or mixed infection; and that a small percentage of sloughing 
keratitis is due to a schizomycetal infection — the aspergillus fumigatus. 
Other active organisms are bacillus coli, bacillus pyocyaneus and 
diplobacilli, especially Morax-Axenfeld diplobacilli. The various micro- 
organisms come from the conjunctiva, the ciliary borders, the nares, 
and the lachrymal passage, and infect some slight abrasion on the corneal 
epithelium and thus start a dangerous form of suppurative keratitis. 
An abscess of the cornea may also occur as the result of an inoculation 
of the infected area with pathogenic micro-organisms, typical forms 
sometimes appearing during scarlet fever, measles, typhoid and typhus 
fevers, and especially during the convalescent stage of smallpox. 
Infected ulcers may be caused by micro-organisms from areas of local 
sepsis in the gums as pyorrhea alveolaris. Simple corneal ulcers are 
treated in precisely the same manner as phlyctenular ulcers. The 
treatment of severe ulceration of the cornea, no matter what its etiology, 
may be summarized as follows: (1) Search should be made for the cause 
of the ulcer, including careful examination for the presence of a foreign 
body, a misplaced cilium, conjunctival inflammation, lachrymonasal 
disease, affections of the rhinopharynx, oral sepsis, and constitutional 
disorders of all types. The active micro-organism should be determined 
by appropriate bacteriological examination. (2) At frequent intervals 
moist heat should be applied by means of lint or flannel compresses 
dipped in water at. a temperature of 120° F, (3) Unhealthy con- 
junctival discharge should be removed by frequent irrigations with 
mercuric chloride (1 : 8000), or a saturated solution of boric acid. 
Protargol (10 per cent.) and argyrol (25 per cent.) are also used. 
Care must be taken lest they stain the affected corneal tissue. (4) 
Sterile atropine drops (4 grains to the ounce [0.25-30.0]) should be 
instilled with sufficient frequency to maintain mydriasis if there is any 
tendency to iritis, and dionin (5 per cent.) is of great service. In the 
opinion of some surgeons, eserine (f to J grain to the fluidounce) is a 
useful drug in the treatment of peripheral ulcers with a tendency to 
perforate the cornea, provided there is no iritis. Occasionally the ten- 
sion rises; if so, myotics are indicated or paracentesis of the cornea. 
(5) The eyes should be protected with smoked glasses; but in severe 
cases and in the absence of purulent conjunctival discharge a dry 
antiseptic dressing, held in place by a light but firmly applied bandage, 



848 DISEASES. 

promotes healing and prevents perforation. It may be worn until the 
floor of the ulcer is covered with epithelium, and removed whenever 
the applications are required. A little iodoform may be dusted upon 
the surface of the ulcer before the bandage is applied, or the ulcer may 
be covered with an iodoform wafer. If the Morax-Axenfeld bacilli 
are present the ulcer should be touched with a 1 per cent, solution of 
zinc sulphate. (6) If the ulcer shows a tendency to spread rapidly, 
it should be curetted and immediately afterward gently touched with a 
probe which has been dipped in pure phenol, or with a wisp of cotton 
which has been dipped in a solution of nitrate of silver (10 grains to the 
ounce), tincture of iodine, or trichloracetic acid. Of these remedies 
nitrate of silver and tincture of iodine may be used in ulcers of the non- 
infective type ; but in ulcers of the infective variety pure phenol or tri- 
chloracetic acid, should be employed. (7) If the ulcer continues to 
spread, the actual cautery may be used, the glowing point of the cautery 
needle being applied to every portion of the ulcer, the area of which is 
outlined by means of fluorescine (2.5 per cent, solution), which will color 
green any portion of the cornea deprived of its epithelium, and there- 
fore furnish a reliable guide to the extent of the destructive process. 
Before these severe applications are made the cornea should be 
rendered insensitive by a few drops of a holocaine solution, and the 
ulcer itself painted with a cotton wisp dipped in holocaine. Indeed, 
there is much evidence to show that the application alone of this drug 
has a distinctly curative influence on corneal ulcers, in this respect 
differing very distinctly from cocaine, which rather retards the cica- 
trizing process. Subconjunctival injections of cyanide of mercury 
(1 : 5000) or of physiological salt solution at times yield satisfactory 
results. If an abscess forms in the cornea, the pus should be evacuated 
by an incision; and hypopyon, or pus in the anterior chamber, may 
be drained by an operation after the manner devised by Guthrie — that 
is, by division of the corneal layers — or, by a simple paracentesis of the 
cornea. 

For the relief of infected ulcer of the cornea due to the pneumo- 
coccus, Roemer's antipneumococcus serum has been employed sub- 
cutaneously in a dose of 3 to 5 mils. Good results have been reported, 
but its action does not seem to be sufficiently certain to allow it to re- 
place other methods. On the other hand, a bacterin prepared from 
the micro-organism which is responsible for the corneal infection, by 
which an active immunization is created, has in a number of reported 
instances been of signal service, but even such a bacterin must not be 
used to the exclusion of the other remedies which have been described. 
In place of antipneumococcus serum, antidiphtheritic serum has been 
employed with success (Darier, Fromaget) in the treatment of severe 
corneal ulceration. 



LACHRYMAL ABSCESS. 849 

Sequelae of Corneal Ulceration. 

After healing of a corneal ulcer the cicatrix consists of a more or 
less dense white spot in the cornea (macula). If these scars are thick 
and white (leukomas), they are irremediable by local medication and 
require surgical interference for relief. If, however, they are diffuse 
(nebulas), much good will follow systematic massage of the cornea, 
aided by the introduction of a small particle of yellow oxide of mercury 
salve. The massage is performed as follows: Apiece of the salve the 
size of a split pea is introduced beneath the upper lid ; upon the closed 
lid a finger is placed, and regular motions made through the lid over the 
surface of the cornea — namely, vertical, lateral, and radial motions, 
the seance being completed by circular movements. The whole should 
last from one to three minutes. Alleman claims excellent results in 
dissipating corneal opacities by the use of electricity by connecting a 
suitably prepared electrode with a battery, the cathode being placed 
directly on the previously anaesthetized cornea and the anode on the 
cheek. Subconjunctival injections of physiological salt solution, 
placed near the corneal margin, have some power in causing absorp- 
tion of corneal nebula. The internal administration of thiosinamin 
has been recommended; the author has never observed encouraging 
results from the use of this remedy or of fibrolysin (15 per cent, solu- 
tion given by injection). Dionin is of service in corneal infiltration of 
recent origin. The destruction of a cicatrix following the perforation 
of a severe corneal ulcer, due to its failure to resist the efTect of intra- 
ocular pressure constitutes a staphyloma. Pressure bandages, myotics 
and, in suitable cases, iridectomy may be of avail in saving sight; often 
enucleation is required. 

LACHRYMAL ABSCESS. 

Lachrymal abscess results from suppuration in a chronically dis- 
tended lachrymal sac owing to the presence of obstruction in the 
nasal duct, and exists as a swelling under the skin at the inner can- 
thus, pressure upon the surface causing an escape of pus through the 
canaliculi. The treatment is practically confined to surgical inter- 
ference — that is, division of the canaliculi and washing out the dis- 
tended sac with antiseptic fluids, and removing the obstruction in the 
nasal duct by the use of probes as soon as the inflammatory symptoms 
have subsided; or, if the skin over the seat of the abscess is thinned 
and rupture is threatened, by free incision downward and outward. 
In purulent discharge from the lachrymonasal duct solutions of formal- 
dehyde (1 : 6000), nitrate of silver (1 : 500), or protargol or argyrol 
(2 to 5 : 100), injected through the passage, favorably modify the 
unhealthy secretion but great care must be taken lest the silver salts 
penetrate through a false passage into the surrounding connective 
tissue and form an indelible stain. Much comfort will ensue from the use 
54 



850 DISEASES. 

of hot compresses over the inflamed area. Excision of the lachrymal 
sac is the best surgical procedure for chronic dacrocystitis ; West's 
operation, or a window resection of the nasal duct through which the 
secretion and tears drain into the nose has been highly commended by 
some surgeons. 

LARYNGITIS (ACUTE). 

The treatment of acute laryngitis is identical in many respects 
with that directed against acute inflammatory processes elsewhere. It 
may be divided into local, external, and internal methods. The con- 
dition of the larynx when acutely inflamed is that of intense hyper- 
emia and irritation, and the object of the physician must be to allay 
this irritability. This is best accomplished by the use of compound 
tincture of benzoin, which is placed in boiling-hot water (1 ounce to the 
pint (30.0 :480 mils.]), and the steam inhaled as it rises from a pitcher 
or as it passes out of the nozzle of a deep coffee-pot. Another method 
consists in the use of a can or wide-mouthed bottle arranged with 
one long and one short tube like a Wolff bottle, the air being drawn 
into the larynx through the short tube, after bubbling through the 
medicated water. (See Inhalations, Part III.) This inhalation should 
be resorted to six or eight times a day, but the patient must not go out 
of doors or into a cold room, as the steam relaxes the parts involved 
and renders them more susceptible to cold. Sometimes advantage is 
gained by adding to this inhalation 1 grain (0.06) of menthol. If 
the patient is unable to remain in an equable temperature, then the 
steam inhaler should be supplanted by a nebulizer, in which should 
be placed the following mixture: 

fy— Mentholis gr. uj (0.20). 

Alboleni fgj (30.0).— M. 

S. — Use as a vapor. 

The patient is directed to inhale this vapor gently, which because of its 
lightness readily passes deeply into the air-passages, and has the effect of 
soothing rather than irritating them as does the spray from an atomizer. 
Rarely in the very acute stages of laryngitis should a watery spray 
be employed to wash the laryngeal mucous membrane, as it is apt to 
increase the irritation. If any aqueous spray is used, as may be 
necessary when the irritation has resulted from the inhalation of dust, 
it may be made up as follows: 

I£— Sodii chloridi gr. xv (1.0). 

Acidi borici gr. x (0.60). 

Sodii boratis gr. x (0.60). 

Aquae rosae f Siij (90.0).— M. 

S.— Use as a spray. 

The external treatment, if the inflammation is exceedingly severe 
and the patient can be confined to bed, consists in the application of 
a mustard plaster over the larynx, or instead a cold compress should 



LEUCORRHCEA. 851 

be applied and kept in place with a long stocking tied around the 
neck. This soon becomes a warm compress by the heat of the body 
and may be kept in place all night. The cold followed by heat pro- 
duces excellent results. A mustard foot-bath and a warm drink on 
going to bed are useful. 

The internal treatment should consist in opening the bowels with 
calomel and a saline purgative if constipation is present, and in the 
administration of full doses of aconite and bromide of sodium or 
strontium, as follows: 

1^ — Tincturae aconiti tt^xI vel lxxx (2.6-5.3). 

Sodii bromidi 5ij (8.0). 

Svrupi lactucarii (Aubergier) . . . . foj (30.0). 
Aquae destillatse . . . . q. s. ad fgiij (90.0). — M. 
S. — Dessertspoonful (8.0) every hour until six or eight doses have been taken. 

This prescription may in many cases be continued until convalescence, 
as it checks cough, soothes the inflamed area, and allays arterial excite- 
ment. Often it is best to omit the aconite after the first few doses. 
In other cases good results follow the use of 2 or 3 minims (0.12-0.20) 
of dilute nitric acid in water every half -hour or hour for six doses. This 
is useful in the early stages only. By the second day the patient should 
be directed to make a heavy application of tincture of iodine over the 
trachea and episternal notch, as high as is possible without the stain 
showing above the collar. In children and in some adults this is well 
substituted by oil of amber and sweet oil in the proportion of 1 to 3 
parts rubbed on the skin. 

For the laryngeal stiffness following the inflammation preparations 
of coca are very useful given internally, and tonics to the general sys- 
tem are needed. In many cases the prescription calling for ammonium 
chloride in the article on Bronchitis is useful. 

Abrams asserts that freezing the skin over the insertion of the inter- 
nal laryngeal nerve, near the thyrohyoid space, where it enters the 
larynx, is a very useful curative measure. This may be repeated 
several times if necessary. The writer has never used this measure. 

LEUCORRH(EA. 

This is a condition — vulgarly known as the "whites" — consisting 
in a hypersecretion from those glands which pour out their contents 
into the vagina or the cervical canal of the uterus, or even into the 
cavity of this organ. It is a state dependent upon many causes for 
its existence, the chief of which is laceration of the cervix uteri in 
child-bearing women. The character of the discharge varies with 
almost every case. In some instances it is thick and tenacious, and 
in others so liquid as to trickle down the limbs and soil the clothing. 
In most of the latter cases catarrh of the Fallopian tubes or ovarian 
irritation and tenderness are present. "When the secretion is very 
thick and tenacious it generally arises from the cervical canal, while 



852 DISEASES. 

that from disorder of the vaginal wall alone, independent of other 
morbid conditions, may be either thick or thin. 

The treatment of these forms of leucorrhcea may be divided into 
two parts — one, that directed to the remedying of the morbid process 
through the use of drugs by the mouth; the other, by their employ- 
ment locally. In obstinate cases the repair of a lacerated cervix or 
the curettement of the uterus is necessary. 

It is needless to state that in that form dependent upon excessive 
lactation or other exhausting manner of life tonics of an active character 
are needed. As a general rule, anaemia will be present, and the follow- 
ing pill will be found of service : 

1^ — Arseni trioxidi gr. ^(0 015). 

Ferri reducti gr. v (0.30). 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulse No. xx. 

S. — One pill three times a day, after meals, for an adult. 1 



Or, 



1$ — Tincturae cinchona? composite . . . . f oij (60.0). 

Tincturae gentianae compositae . q. s. ad f 5iv (120.0). — M. 
S. — Dessertspoonful (8.0) three times a day, after meals. 



When any preparation of iron is used care must be taken that the 
bowels are kept active and that the stomach is not disordered. Asso- 
ciated with the use of these internal remedies should be a moderate 
amount of exercise and the avoidance of late hours and rich foods. 

The local applications which are of value in these states consist in 
counterirritation and vaginal injections or painting with proper fluids 
the mucous membrane of the parts from which the discharge comes. 
In the leucorrhcea dependent upon irritation of the ovaries associated 
with catarrh of the Fallopian tubes the use of small blisters formed by 
the employment of cantharidal collodion or a cantharidal plaster over 
the groin on either side is often accompanied by good results. At 
the same time the vaginal surfaces surrounding the cervix uteri may 
be painted with a mixture of iodine, phenol, and chloral, such as was 
used by Goodell, as follows: 

1$ — Iodi resublimata 5iv (16.0). 

Phenolis, 

Chlorali hydrati aa 5.i (30.0). 

Rub the iodine and chloral in a glass mortar into a powder and add the 

phenol. 
S. — Formula. To be used by the physician only. 

The following pill may also be employed: 

I^ — Hydrargyri chloridi corrosivi . . . gr. § (0.03). 

Fiant pilulse No. xx. 
S. — One pill three times a day after meals, or a tablet triturate may be used instead 
of a pill. 

1 In this prescription the small amount of iron given will probably be noted, but this 
is done advisedly, as iron does as much good to the blood in small as in large amounts 
under most circumstances. (See Iron.) 



LID ABSCESSES. 853 

The remaining treatment of watery leucorrhcea consists in the use 
of astringent injections. A cheap astringent injection is made by 
adding 1 ounce (30.0) of powdered white-oak bark to each pint (480 mils.; 
of hot water, or tannic acid and glycerin in the proportion of 1 ounce 
to 2 quarts (30.0:1920) of warm water. Ringer recommends the 
following : 

~Rf— Sodii bicarbonatis 3j (4.0). 

Tincturae belladonnas foliorum . . . • foij (8.0). 

Aqua Oj (480 mils.) .—M. 

S. — Use as a vaginal wash. 

Where the discharge is fetid a solution of permanganate of potas- 
sium should be used as an injection in the strength of \ drachm to 1 
pint (2.0:480 mils.) of water. 

In purulent vaginitis, specific or otherwise, the following injection 

is serviceable: 

3— Creolini f3ssvelf3ij (2.0-8.0). 

Fluidextracti hydrastis f 5nss (10.0). 

Aquae fgviij (240.0).— M. 

S— Add 2 tablespoonfuls to a pint (30.0 : 480 mils.) of hot water, shake 
thoroughly and use as an injection. 

A very useful astringent injection is: 

fy— Zinci sulphatis 3j (4.0). 

Alumini sulphatis 5j (4.0). 

Glycerini f§vj (180.0).— M. 

S.— A tablespoonful (16.0) to each quart (1 litre) of water. 

The injected fluid should always be as hot as the patient can bear, 
as tepid injections are harmful. 

Sometimes a tampon thoroughly saturated with a powder of iodo- 
form and tannic acid, equal parts, and packed around a discharging 
uterine cervix is of service. 

^Tien using vaginal injections it is important to remember that 
they should be in large quantities. Nothing is more antagonistic 
to true asepsis than the usual manner in which these applications 
are made. Often a pint of the solution is placed in a basin over which 
the woman squats, and by means of a syringe forces the liquid into the 
vagina as fast as it run out, thereby filling the syringe joints with the 
dissolved secretions, and returning to the vagina as soon as they flow 
away the impurities which have left it. The only proper way to give 
such an injection is to use a fountain syringe or to have the solution in 
one basin, to the extent of 1 gallon (4 litres), while the patient squats 
over a second basin, into which the impure liquid may run. 



LID ABSCESSES. 

Lid abscesses are seen more frequently in children than adults, as 
the result of injury, the sequel of acute illness (epidemic influenza, 
pulmonary catarrhs, fever, etc.), or from local infection; under the 



854 DISEASES. 

latter circumstance they may assume a gangrenous type. The treat- 
ment is that for any form of abscess — pouftices, preferably in the form 
of hot compresses, early incisions, antiseptic solutions, and tonics. 



LUMBAGO. 

This is a form of myalgia or muscular rheumatism of the muscles 
of the loins and small of the back, and is frequently the result of lifting 
heavy weights, or it is due to other strains. In many cases acupunc- 
ture is very useful, particularly if the trouble is bilateral. (See Part III.) 
Sometimes after the employment of this measure the patient can 
straighten the back at once and retain that position. In other instances 
antipyrine or acetanilide, in 5- to 10-grain (0.30-0.60) doses of the 
former and 4- to 8-grain (0.25-0.5) doses of the latter are of service, 
and iodide of potassium and salicylic acid are not to be forgotten if 
the condition of the patient does not rapidly improve. Aspirin, phe- 
nacetin, and phenyl salicylate (salol) are also useful, combined or alone. 
A large hot poultice applied to the back is often efficacious in obstinate 
cases. Sometimes the use of a hot foot-bath and a Dover's powder on 
going to bed will produce a cure, and ironing the back with an ordinary 
hot laundry iron at a proper heat, a piece of newspaper or cloth being 
placed over the skin under the iron, is very efficient. Counterirritation 
in the shape of a blister, a mustard plaster, or capiscum draft will 
often give relief. Strapping often relieves sacro- iliac pain. 

Where these measures fail, an ether or chloride of ethyl spray may 
be played on the centre of the painful area until the skin is greatly 
blanched. 

MALARIAL FEVER. 

(See Intermittent and Remittent Fevers and Pernicious 
Malarial Fever.) 



MANIA (ACUTE). 

Space is wanting to consider the thorough and complete treatment of 
mania as it comes to the neurologist. All that can be mentioned here 
are temporary measures suitable for cases which are brief in their course. 

For the rapid quieting of the patient hyoscine hydrobromide may 
be used hypodermically in the dose of -gV grain (0.0012). In other 
instances, if the kidneys and heart are healthy, full doses of chloral 
may be used; and if an active preparation of cannabis indica can be 
had, at least 1 grain (0.06) of the solid extract or \ to 1 drachm (2.0-4.0) 
of the tincture should be employed. Cannabis indica will be found 
much more serviceable if 60 grains (4.0) of one of the bromides be 
combined with it. 

When a patient suffering from mania is so violent that nothing can 



MENINGITIS. 855 

be done with him, he should be held, and an emetic dose of T V grain 
(0.005) of apomorphine be given hypodermically to produce vomiting 
and so relax the muscular system; or he may be tied or anaesthetized 
sufficiently to enable the physician to administer proper remedies. 
Sometimes full doses of morphine are needful, or a cold douche to 
the head while the body is in a tub of hot water is of service. In others 
a hot cabinet bath or Russian bath is a valuable sedative. (See Heat.) 

MELANCHOLIA. 

This is not the place for the discussion of melancholia of so severe 
a form as to amount to insanity, since the treatment of this latter state 
is very various and largely depends upon the skill of alienists. 

There is one form of melancholia, however, which may often be 
quickly relieved by a simple measure. It is that dependent upon the 
condition of the system in which oxaluria is present. Whenever an 
individual complains of melancholia the urine should be examined, 
and if an excess of oxalate crystals are found, the undiluted, freshly 
made nitromuriatic acid should be given in the dose of 5 minims (0.3) 
after each meal in a half-tumblerful or more of water. In order to 
guard against errors in diagnosis it is well to remember that pears, 
tomatoes, rhubarb, and cabbage all cause oxalates to appear in the 
urine for a short period after their ingestion. 

MENINGITIS (ACUTE). 

In a large proportion of cases the development of meningitis is 
secondary to some other state of disease, as, for example, otitis media 
or croupous pneumonia. Under these conditions the treatment must 
be governed by the exciting cause. 

When meningitis is due to tuberculosis we can do nothing save to 
give relief from pain, if it is present, by sedatives and lumbar puncture. 
When it is due to an infection of the meninges by the pneumococcus or 
typhoid bacillus this is also true. If it is caused by the diplococcus 
intracellularis of Weichselbaum, that is, if it be true cerebrospinal 
meningitis, the only remedy of any real value is the antimeningitis 
serum, which is to be injected into the spinal canal after an equal 
quantity of cerebrospinal fluid has been withdrawn. (See Antitoxin.) 
It is to be recalled that this serum acts as a bacteriolytic or bactericidal 
agent rather than as an antitoxin. (See Uro tropin.) In the way of 
palliative measures the following measures may be resorted to. 

During the first acute stage an ice-bag should be applied to the head 
both for its local influence and its antipyretic effect, and leeches may 
be put at the nape of the neck with advantage. As the disease advances 
and the nervous disorders of the affection become marked, sedatives 
are required to allay the twitchings, muscular spasms, or convulsions, 
and for this purpose no drugs excel chloral and the bromides. The 



856 DISEASES. 

doses to be used vary with the violence of the symptoms, but it may 
be stated that the chloral should rarely, if ever, be used in doses 
above 10 grains (0.60), and the bromides given in the dose of from 
20 to 40 grains (1.3-2.60). If coma comes on, a large blister should 
be applied to the nape of the neck. 

Quinine has been recommended in meningitis, but it is absolutely 
contraindicated, as it predisposes to meningeal congestion. It may be 
employed only in convalescence, and then used most carefully. 

The treatment of the advanced stage of meningitis must be neces- 
sarily supportive. Alcohol should be given with the food if weakness 
is present, and a very simple or milk diet insisted upon. 

If symptoms of cerebral pressure are marked, lumbar puncture 
should be performed, the technique of which is described under 
Lumbar Puncture and Tropacocaine. Of course, no drug is injected. 
In many cases the relief is only temporary, but in a few it is permanent. 

MIGRAINE. 

Migraine is a form of head pain usually limited to one side of the 
head — hemicrania. It is often characterized by the presence of severe 
boring pain in the eyeball or over the brow on one side. Associated 
with or preceding this pain there may be some dimness of vision or 
even a true transient amblyopia. The exact pathology is not clear, 
and so our treatment of it is perforce largely empirical. As soon as 
the first warning symptom develops a bottle of citrate of magnesium 
should be taken, even if constipation is not present. Before the 
introduction of the coal-tar products as pain-relievers, the best treat- 
ment of the attack of pain consisted in ordering the patient to bed and 
giving him 15 to 30 drops (1.0-2.0) of tincture of gelsemium, with J 
to i grain (0.015-0.03) of extract of cannabis indica every two hours. 
If the heart is feeble, the fact that gelsemium is a cardiac depressant 
must not be forgotten. So far as the other measures for relief of the 
individual attack of pain are concerned, reference should be made 
to the article on Neuralgia. For the cure of the condition which 
results in the attack, the endeavor should be to keep the liver active, 
since the failure of this organ to destroy the poisons which cause an 
attack, and its failure to prevent fermentation in the bowel by the 
proper secretion of bile, is supposed to be the chief cause of the dis- 
order. The use of sodium phosphate, taken in hot water every 
morning on first arising, does good in many cases, particularly if the 
patient also takes some one of the salicylates several times a day. 
Rachford recommends: 



-Sodii sulphatis 
Sodii salicylatis 
Magnesii sulphatis 
Lithii benzoatis 
Tincturse nucis vomica? 
Aquae destillatse 



gr. xxx (2.0). 
gr. x (0.6). 
gr. j (3.3). 
gr. v (0.3). 
miij (0.2). 
fgiv (120.0).— M. 



MUSCM VOLITANTES. 857 

This mixture should be made up in large quantity and placed in a 
siphon by one of the concerns which charge soda-water, and from one- 
quarter to one-half glass of this water at ordinary temperature is to be 
taken every morning at least half an hour before breakfast, enough 
being used to ensure an adequate bowel movement during the forenoon. 
The ingredients meet several indications, for the sulphates of sodium 
and magnesium act as laxatives, the salicylate of sodium acts as a 
gastro-intestinal antiseptic and cholagogue, and the lithium benzoate 
aids in the elimination of effete materials representing perverted 
metabolism. The small dose of nux vomica is introduced to mask 
the soapy taste of the mixture. A more agreeable mixture, put 
up at my suggestion in the form of an effervescent salt, consists of 10 
grains (0.65) of salicylate of strontium, 5 grains (0.3) of lithium 
benzoate, and 60 grains (4.0) of Rochelle salt. This dose should be 
repeated every half-hour until purging is free. Associated with this 
treatment, additional doses of salicylates may be used if needed, or 
benzoate of sodium may be given. The author prefers 10- to 20-grain 
doses of ammonium benzoate given in capsule. When evidences of 
intestinal fermentation are marked, the following pill may be used, 
devised by M. Allen Starr; it should be coated with phenyl salicylate 
to ensure its entrance into the bowel before it is dissolved: 

]$ — Sodii phenolsulphonatis gr. v (0.3). 

Potassii permanganatis gr. j (0.06). 

Beta-naphtolis gr. j (0.06).— M. 

S. — One after meals and at night. 

An occasional free catharsis with blue mass is advisable in many of 
these cases. Usually 5 to 10 grains (0.3-0.6) once a week and fol- 
lowed by a saline is sufficient. It is essential that all causes of systemic 
and nervous worry be removed in these cases. Excessive sexual 
indulgence is often a cause of the attacks, and it must be interdicted. 
(See also articles on Headache and Neuralgia.) 

Some cases of migraine due to intranasal pressure are relieved by 
turbinectomy or straightening the nasal septum. 

MUSOffi VOLITANTES. 

Muscae volitantes is the name applied to the dark specks which 
patients frequently see floating across their fields of vision, especially 
if the eyes are directed toward a bright sky or a white page. Usu- 
ally they indicate no disease of the vitreous humor, and the ophthal- 
moscope fails to detect abnormal changes. They are attributed to 
torpidity of the liver by the laity. Muscse volitantes may indicate 
eye-strain, and if the refraction is abnormal this should be corrected; 
a mild course of alteratives is often a useful adjuvant. 



858 DISEASES. 

MYALGIA. 

Soreness of the muscles either on pressure or on movement may be 
dependent upon a number of causes, such as strains, bruises, toxsemia, 
or inflammation due to cold. Here, as in many other states, the treat- 
ment should be divided into the external and the internal methods. 
Of the internal remedies, the best are the salicylates or the iodide of 
potassium if rheumatism be the cause of the trouble. On the other 
hand, if a bruise or cold be the cause, the chloride of ammonium will 
be of service in 10- or 20-grain (0.60-1.3) doses given in a solution 
with fluidextract of liquorice. (For prescription see Bronchitis.) Other 
remedies which may be tried with a good chance of success are full 
doses of an active fluidextract of cimicifuga (20 minims to 1 drachm 
[1.3-4.0]) or the citrate or acetate of potassium in 20-grain (1.3) doses. 

The local medications are numerous, but only a few can be consid- 
ered as worthy of routine employment. The chief one is iodine ; in 
the form of the pure ointment or the ointment diluted one-half with 
lard if the skin is easily irritated. Another method is to employ a 
liniment, well rubbed into the skin, made up as follows : 

1$ — Tinctures belladonnae foliorum . . . . foiss (6.0) 

Tincturae aconiti f 5vi (24.0). 

Tincturae opii t'oij (8.0). 

Linimenti saponis . . . . q. s. ad t'ovj (180.0) — M. 
S. — Poison. To be used externally and only as a liniment. 

Sometimes chloroform liniment is singularly successful, and poul- 
tices applied as hot as can be borne and covered by oiled silk and cotton 
to retain the heat are often of great value. Massage or good rubbing 
is also a sine qua non for the successful treatment of this state. 



NASAL CATARRH (ATROPHIC). 

In atrophic nasal catarrh the nostrils are roomy and the mucous 
membrane red and shiny. The formation of connective tissue has 
to a great degree obliterated the delicate serous glands, and the dis- 
charge of mucus, no longer diluted, forms inspissated crusts, which 
adhere to the mucous membrane of the septum and turbinated bones. 
Areas of ulcerated or abraded membrane are disclosed upon removal 
of these adherent crusts. 

The turbinated bones are gradually absorbed and the secreting 
surface thereby much reduced. Sometimes the wasting is so great 
that the posterior wall of the pharynx is clearly visible through the 
anterior nares. The inspissated secretion may form a cast of the 
nostril, and as fresh layers form underneath, the oldest part is raised 
until the whole interior of the nostril becomes a mass of decomposition, 
giving rise to an overpowering stench. This form of catarrh causes 
loss of the sense of smell, and the odor is not recognized by the patient 
himself. Ulceration or caries of the bony structure produces an odor 



NASAL CATARRH. 859 

even worse than the so-called ozoena. The pharynx suffers from the 
general wasting, and presents a dry, varnished appearance called 
pharyngitis sicca, which is rather a symptom of nasal atrophy than 
a separate disease of the pharynx. 

The indications are the removal of all accumulations in the nose 
and nasopharynx and the healing of abraded or ulcerated surfaces. 
The early removal of dead bone is imperative, and what secreting 
surface remains must be stimulated as far as possible, to compensate, 
in a measure, for the glands that are hopelessly destroyed. In other 
words, efforts are directed toward producing a compensatory hyper- 
trophy of the glandular tissue that remains. Therefore with the use 
of antisepsis alteratives and local stimulation are combined. 

The nose should be thoroughly cleansed with an alkaline wash — 
Dobell's solution — warmed to increase its solvent power. To relieve 
the odor, we may increase the amount of phenol or substitute for it 
eucalyptol and thymol in the wash. Euthymol contains both of these 
and may be added to the wash. Its own pungent odor masks some- 
what the offensive odor. Permanganate of potassium may be used in 
weak solutions, but it is painful except when sensation is entirely lost. 
Peroxide of hydrogen is valuable used in an atomizer in the strength 
of 1 part to 10 or 1 to 20. After this has softened the crusts they 
should be dislodged by the further use of a warm alkaline spray, and 
after the cleansing is complete ichthyol, pure or diluted one-half with 
water or albolene, is applied by means of an applicator. Often a much 
weaker solution of ichthyol will do equally well. The patient may be 
given a salve of: 

1^— Ichthyolis gr. xl (2.6). 

Mentholis . . . gr. v (0.3). 

Petrolati alLi . gj (30.0).— M. 

A piece of this is to be inserted into the nostril, after using a douche, 
each night. 

The solutions are best applied by means of an atomizer, or post- 
nasal syringe in the hands of the physician, or by snuffing from the 
hand or cup. 

The odor, if due to decomposition, is much decreased as soon as 
the passages are clear. The discharge must never be allowed to 
re-accumulate or much gain will be lost. 

Ulcerations require local stimulation by a strong solution of nitrate 
of silver or a superficial application of the flat surface of the galvano- 
cautery heated to dull redness. Necrosed bone should be removed, 
and it is often found detached in the nostril. 

Local stimulants should be judiciously combined with alteratives. 
Powders of nitrate of silver in starch, varying in strength from 1 to 
10 grains to 2\ drachms (0.06-0.60: 10.0) of the latter, may be blown 
into the nostrils by means of an insufflator. Cover gently the whole 
surface with a thin layer, and use it only of sufficient strength to be 
slightly felt. Nitrate of silver in solution, 1 to 10 grains to 1 fluidounce 



860 DISEASES. 

(0.06-0.6:30.0) gives better results at other times when applied to 
the mucous membrane. The physician must avoid overstimulating, 
and so exhausting, the glands which it is wished to strengthen. The 
use of alteratives may alternate with the silver salt and iodide of potas- 
sium, and this may be done by using solutions of iodine and glycerin, 
as recommended for hypertrophic nasal catarrh. Internally, we may 
employ iodide of potassium, to increase nasal secretions, and mucous- 
membrane stimulants and tonics. Attention should also be paid to 
the activity of the skin. 



NASAL CATARRH (CHRONIC). 

Chronic nasal catarrh is essentially a disease of civilization, which 
may occur at any period of life, but more commonly develops from 
youth to early adult life. 

Although very prevalent among the upper classes, it is in the lower 
ranks that it most frequently reaches its later stages and its worst 
forms. This does not result from lack of opportunity for treatment, 
but from the ignorance or indifference which this class show to dis- 
eases while there is no suffering and no interference with business. 

Hypertrophic nasal catarrh commonly has its origin in a neglected 
cold in the head or in a series of colds occurring in rapid succession, 
keeping the nose in a congested state until the erectile tissue covering 
the turbinated bones loses in a measure its power of contracting, and, 
decreasing the calibre of the nostrils, becomes a source of permanent 
obstruction to breathing. 

As the disease advances there is increased susceptibility to cold. 
Slight exposure produces a stuffy feeling in the nose. The nostrils 
may become completely occluded; usually, however, only one side 
at a time is obstructed at first, the obstruction showing a tendency 
to change sides. This change is most noticeable on turning in bed, 
the lower side usually stopping, and on changing the posture the 
obstruction is reversed, the clearing being accompanied by a crackling 
sensation. A slight tickling cough and tendency to clear the throat 
in the mornings may result from irritation of the pharynx or larynx. 

The first indications for treatment are the reduction of inflammation 
and restoration of the breathing-space. 

As the chief function of the nose is respiratory, the re-establishment 
of free nasal respiration, combined with the liberal use of antiseptic 
washes, will lessen the inflammation and irritation and produce a 
healthier state of the secretions. 

The writer places cleanliness at the head of the list of remedial 
measures. The alkaline wash recommended for Coryza, sprayed 
into the nose by a hand atomizer or gently snuffed from the palm of 
the hand or from a small cup, gives good results. The hand warms 
the solution slightly, but when snuffed from a cup the solution should 



NEPHRITIS. 861 

be artificially warmed. This wash may be used two or more times a 
day. 

The nasal douche should never be used where there is nasal obstruc- 
tion, on account of the risk of forcing the solution into the Eustachian 
tube and causing catarrh of the middle ear. 

In addition to the antiseptic wash where the mucous membrane is 
congested and irritable, the treatment recommended for coryza may 
be instituted for a few days with good results. A solution composed 
of equal parts of water of hamamelis and water or a dilute solution of 
hydrastis may be sprayed into the nose during the acute stage. 

A little later a spray of ferric alum, 5 grains to the ounce (0.3-30.0), 
may be applied carefully in an atomizer by the physician. It is not 
advisable to use alum in any considerable strength in the nose, as its 
continued use is liable to impair the sense of smell. 

The alterative and absorbent action of iodine makes it a valuable 
remedy for local application in very chronic nasal catarrh. It should 
be combined with glycerin in the strength of 6 or 8 grains to the ounce 
(0.40-0.50:30.0), with enough potassium iodide to make a solution. 
Apply this by means of a piece of absorbent cotton on the end of an 
applicator, along the floor of the nose, until it reaches the pharynx. It 
is needless to say that such an application as this should be made with 
the utmost gentleness. The cotton should project beyond the probe, 
and care should be taken to avoid bruising the tissues. 

After the irritation has subsided, as shown by the disappearance 
of the livid color and lessened sensibility, any remaining hypertrophied 
tissue should be removed by a snare or the galvanocautery. 



NEPHRITIS (ACUTE). 

In the early stage of onset, for the reduction of inflammation cir- 
culatory depressants are to be resorted to, and aconite is generally 
most serviceable. The patient should be kept quietly in bed and 
given a milk diet, and hot compresses, cups or leeches used over 
the loins if the urine is scanty. Blisters are not advisable, as the 
irritant substances producing them may be absorbed and cause in- 
creased renal irritation. The restlessness will generally be quieted 
by the aconite; but if this fails, resort must be had to bromides or 
small doses of opium, which must be given cautiously, as these drugs 
are not readily eliminated when the kidneys are diseased. Cannabis 
indica is thought to be of great service if bloody urine is present, but 
chloral is generally too irritating to the kidney to justify its employ- 
ment. The appearance of large amounts of blood in the urine at 
about the fifth day of the illness is an indication, according to Sydney 
Ringer, for the use of drop doses of tincture of cantharides, given 
every few hours. Personally the author would be afraid to use this 
method of treatment. 



862 DISEASES. 

Should the urine be scanty and of high specific gravity, and con- 
stipation be present, some calomel, followed by a purgative dose 
(J an ounce [16.0]) of sulphate of magnesium should be used to aid 
in the elimination of impurities by the bowel. Warm mucilaginous 
drinks, as flaxseed tea, are of service, and the use of the citrate of 
potassium and the sweet spirit of nitre with copious draughts of pure 
water should be resorted to to increase urinary flow and promote the 
action of the skin. 

If dropsy or symptoms of uraemia (see Uraemia, Part IV.) come on, 
they may be relieved by the use of hydragogue purges, such as elate- 
rium, which is particularly useful in that it is supposed to aid in the 
elimination of urea by the bowel. If vomiting is present, elaterium 
ought not to be used, as it irritates the stomach. Jaborandi or pilo- 
carpine may be used to sweat the patient at this time or in the earlier 
stages with advantage; J grain (0.008) of the hydrochloride should be 
given hypodermically, and repeated in fifteen minutes if no sweat 
appears; but it should never be forgotten that when the heart is feeble 
or the patient very susceptible pilocarpine may produce serious col- 
lapse. This can sometimes be guarded against by the simultaneous 
use of strychnine in A grain (0.003) doses. Hot-air baths or hot packs 
are often useful to provoke sweat and are much safer than pilocarpine. 
(See Heat, Part III.) 

The treatment of the later stages consists in the use of stimulants 
to the kidneys to arouse them from the atony consequent upon the 
excitement of inflammation. To this end digitalis and squill, or digi- 
talis and calomel, or citrated caffeine may be used in small amounts, 
or in their place the compound spirit of juniper or gin may be used as 
the case progresses. If the renal structure is persistently atonic, \ to 
1 minim (0.03-0.06) of the tincture of cantharides at each dose may 
be used, and, as anaemia is often a prominent symptom, tincture of 
the chloride of iron, which is both a diuretic and a tonic, should be 
resorted to. If renal hemorrhage is excessive, gallic acid and ergot 
are indicated to control the bleeding. A meat-free diet should be 
rigidly enforced. 

NEPHRITIS (CHRONIC). 

The treatment of chronic nephritis is a very different matter from 
that devoted to the cure of the acute form. It is almost, if not quite, 
impossible to cure the condition present, and we can only strive to 
improve the state of the kidneys and other organs by care and the use 
of proper drugs. As Tyson has aptly put it, we must try to arrest 
the development of the renal lesions and improve the general health, 
treat the symptoms which are not dependent upon the nephritis, 
except indirectly, and, last, treat those signs which are due to the 
nephritis itself. To arrest the disease all alcoholic drinks should 
be avoided as far as possible, and business cares and worries be cast 



NEPHRITIS. 863 

aside. Great care should be taken to avoid cold, and a warm climate 
is generally to be recommended to the patient, since sudden changes 
of temperature tend to produce congestion of the kidneys by the chill- 
ing of the skin. 

The diet and drink are important considerations, and should con- 
sist largely of milk and easily digested starchy foods like rice and 
well-cooked barley. Many physicians direct that skimmed milk be 
used. The author believes that this advice is not wise, as it deprives 
the patient of the nutritive fats, which he needs and which are not 
contraindicated, whereas the proteids of skimmed milk, while they are 
the best form of albuminoid food we can give, are not so advantageous, 
but have to be used to maintain nutrition. If the cream in the milk 
disagrees with the patient, it may be removed or the milk may be 
diluted with some effervescent water like Vichy. It is rarely essential 
to put the patient on a strict milk diet. 

The treatment suggested so far is applicable to all forms of chronic 
nephritis, but there are symptoms and complications of both the inter- 
stitial and parenchymatous forms of the disease which require special 
treatment. If the urine be scanty in the parenchymatous form, and 
the heart is feeble, digitalis and caffeine are useful to improve the 
renal circulation and act directly on the kidney. In other cases we 
may prescribe the well-known pill of digitalis, squill, and calomel. 
These drugs not only increase urinary flow, but also decrease albumi- 
nuria in many cases. In still other instances we may give the acetate 
and bitartrate of potassium as diuretics, which are particularly valuable 
if combined with digitalis in those cases of albuminuria dependent 
upon failure of the heart muscle. These remedies are also of value 
to relieve the dropsy, and one of the most efficacious forms of treat- 
ment is a combination of the bitartrate of potassium and juniper- 
berries, so that 1 ounce (30.0) of the former is dissolved in 1 pint 
(480 mils.) of an infusion (1 ounce [30.0] to the pint [480 mils.]) of the 
latter and taken in twenty-four hours. A most valuable aid in de- 
creasing the albuminuria is the use of 1 minim of tincture of cantha- 
rides in water three times a day, particularly if the kidneys seem 
torpid and secrete too little urine. If dropsy develops (see Dropsy), 
hydragogue purges are useful, such as jalap and elaterium. 

Very great benefit can often be obtained from the use of nitroglycerin 
when the arterial tension is high, giving it in ascending doses beginning 
with yJj-Q grain (0.0006) three times a day. This decreases the albu- 
minuria, if it is present, low r ers arterial tension, and benefits the heart. 
Another drug of value in those cases of chronic contracted kidnev 
which have their origin in gout or syphilis is iodine in the form of iodide 
of sodium or strontium. This may be given in 10-grain (0.60) doses 
three times a day with great advantage to old persons with well-ad- 
vanced atheromatous changes. 

The treatment of ursemia, should it be mild or severe, is important, 
and the reader is referred to the article on that subject (see Uraemia). 



864 DISEASES. 

The various forms of hot baths should also be employed to aid the 
skin in eliminating poisons and so relieve the kidneys. The anaemia 
in parenchymatous nephritis is to be combated by the use of the tincture 
of the chloride of iron, or Basham's mixture (see Iron), and oxygen 
inhalations. It is, however, a mistake to use large doses of Basham's 
mixture. Chronic parenchymatous nephritis is an incurable disease, 
and the most that Basham's mixture can do is to combat the anaemia 
and act as a diuretic. Small doses of iron will do as much for the 
anaemia as large ones, and will not disorder digestion, and the diuretic 
effect can be obtained by using liquor ammonii acetatis if it is 
desired. 

In the interstitial form of the disease iron must be used with caution, 
or not at all, as it is apt to produce headache and perhaps conduces to 
the development of uraemia. It is in this form of renal disease that 
nitroglycerin does the most good by lowering arterial tension and so 
saving the heart from excessive labor, but it is not to be forgotten that 
in many cases a high blood-pressure is essential to maintain the circu- 
lation through narrow and tortuous fibroid vessels. 

NEURALGIA. 

Like headache, neuralgia gives rise to much of the suffering expe- 
rienced by active persons who are not sick enough for bed. It affects 
people in every walk of life, and may be so severe as to incapacitate 
the most powerful man. 

The causes of neuralgia are very various, but they may be briefly 
stated to depend chiefly upon malnutrition and anaemia, overwork, 
nervous excitement with consequent reaction, and upon reflex irrita- 
tion from diseased organs, as in the case of supraorbital neuralgia from 
eye-strain or pelvic neuralgia from ovarian irritation or uterine inflam- 
mation. Nerves functionally diseased are always more or less active 
than normal; that is, hyper-excited, or depressed, above or below par. 
In both cases they must be brought back to their normal tone by 
appropriate remedies, and these consist in nervous excitants and 
nervous sedatives. To give a nerve already depressed the additional 
depression of a bromide, or a nerve excited the additional excitement 
of strychnine, is harmful. 

From what has just been said, it becomes evident that the physician 
must always determine the condition of the system of his patient and 
the causes of the neuralgia before administering remedies. 

The treatment of neuralgia, from its curative standpoint, may be 
divided into the use of tonics, laxatives, nutritives, and palliatives. 
(See Migraine.) 

Where neuralgia is associated with anaemia no hope of permanent 
relief can be looked for unless iron and arsenic are used until the 
anaemia is cured, and it is often necessary to combine with these drugs 
the use of cod-liver oil and bitter tonics. These are the cases, too, 



NEURALGIA. 865 

in which mix vomica and strychnine raise the depressed nerves to 
increased activity, and so bring relief. How they do this is not known, 
but we know enough to recognize one or two important facts. Strych- 
nine is certainly a nervous stimulant, and is also a stimulant to the 
anterior columns of the spinal cord. It probably also acts upon the 
trophic centres in the anterior cornua of the spinal cord, and by stimu- 
lating these centres increases the nutrition of the tributaiy nerve-fibres. 
It is needless to state that the neuralgias of syphilis and tuberculosis 
are to be treated by the remedies usually directed to the relief of these 
affections, while at the same time the pain itself is carefully controlled 
by appropriate palliatives. 

When nervous exhaustion causes neuralgia, phosphorus is a useful 
remedy, particularly in those cases which are convalescing from acute 
fevers. 

Sometimes malarial poisoning produces a violent form of supra- 
orbital pain known as "brow ague," which is to be relieved, not by 
ordinary remedies, but by large doses of quinine. 

The relief of the states producing neuralgia having been spoken of, 
it yet remains to consider the measures to be adopted for the cure 
of an attack. Fortunately the recent advances of therapeutic study 
have placed in our hands a large list of drugs not apt to produce a 
habit after prolonged use, comparatively safe though active, and not 
of disagreeable taste or evil general effect. By these terms the writer 
refers to antipyrine, acetanilide, aspirin, and phenacetin, all of which 
possess wonderful power in the alleviation of pain dependent upon 
true nervous involvement. In order to avoid failure in the use of these 
drugs in the relief of headache, we must always remember that their 
field of service is that of neuralgic pain, not other pains. Antipyrine 
is to be used in the dose of 5 to 10 grains (0.30-0.60) for ordinary 
neuralgia and more for the pain arising from the crises of locomotor 
ataxia, acetanilide in the dose of 3 to 8 grains (0.20-0.5) for the same 
purposes, and aspirin and phenacetin in the same amount as anti- 
pyrine. Aspirin in tablet or capsule in the dose of 5 to 20 grains (0.3- 
1.3) is very efficacious. 

Upon these remedies combined with caffeine and the bromides 
according to circumstances, we now depend, and the following pre- 
scriptions will be found of service: 

1$ — Antipyrinsp gr. xxx vel 5j (2.0-4.0), 

Caffeinse citratae gr. xx (1.3) — M. 

Fiat in chartulas No. x. 

S— One every thirty minutes unti] relieved or six doses are taken. 

The following may be of use also: 

]$— Antipyrinae gr. xxx vel 5 j (2.0-4.0). 

Potassii bromidi 3iij (12.0). — M. 

Fiat in chartulas No. x 
S. — One every thirty minutes until relieved, or until six doses have been taken 
55 



866 DISEASES. 

Or, when the caffeine in the first prescription causes nervousness— 

I$— AntipyrinaB gr xxx vel 3j (2.0-4.0). 

Caffeinae citratse . . gr x (0.60). 

Potassii bromidi . . . . . . . . 3iij (12.0). — M, 

Fiat in chartulas No. x 
S. — One as above. 

In any one of these prescriptions acetanilide or acetphenetidin may be 
substituted for antipyrine, and they should be used in preference to it 
if the heart is weak. Full doses of gelsemium may be used. 

A very effective remedy in some cases of neuralgia of the fifth nerve 
is croton chloral in from 5- to 20-grain (0.3-1.3) doses in pills or 
capsules of 5 grains (0.3) each. 

In some cases of anaemic neuralgia of the head nitrite of amyl 
inhalations have proved useful, probably by reason of the cephalic 
flushing produced by this drug. 

In some cases repeated doses of castor oil, 1 to 2 ounces (30.0-60.0) 
a day, seem to exercise a very extraordinary influence in relieving neu- 
ralgic pain. Such cases probably depend upon deficient activity of 
the bowel with retained toxic material which gains access to the blood. 
(For Migraine, see article on that subject.) 

A very large number of local applications have been used with success 
in obstinate neuralgias and other cases not so difficult of cure. Cocaine 
cannot be applied, as it does not penetrate the skin, but relief can 
sometimes be obtained by the local use of a menthol pencil rubbed 
over the spot if it be limited in area. Correction of eye-strain by 
glasses may relieve cephalic neuralgia. 

Where the nerve is very superficial it can often be treated by cold 
with great success. This is accomplished by freezing the parts with 
an ether, chloride of ethyl, or rhigolene spray, or by the application 
of a small piece of ice covered with salt to the part. 

Exceedingly severe neuralgia of the fifth nerve has been treated 
successfully by the injection of 90 per cent, alcohol with four grains 
of cocaine to the ounce, the quantity of the injection being from 15 
to 30 minims (1.0-2.0 grammes). Injection of the superior branch 
is questionable because of possible trophic disorders in its distribution, 
as in the eye. A straight hollow needle, large enough to carry a blunt- 
pointed stylet, but having a sharp point and marked off in centimeters, 
is employed. The sharp point of the needle is used to penetrate the 
skin. After the skin is penetrated, the stylet is pushed beyond the 
point so that the vessels will not be injured, and the combined needle 
and stylet is pushed in in such a way as to reach the nerve at ts 
foramen. When the middle branch is to be injected, the point of 
entrance is on the line of the posterior border of the ascending orbital 
process of the malar bone, which line is prolonged to the lower border 
of the zygoma. The needle is inserted half a centimeter posteriorly 
to this point and is directed vertically to the antero-posterior line, but 
inclines slightly upward in such direction that at the depth of the fora- 



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NIPPLES (SORE). 867 

men rotundum it reaches the level of the inferior extremity of the nasal 
bones. In the ordinary individual the needle when introduced 5 cen- 
timeters meets the nerve as it emerges from the foramen rotundum. 
When the inferior branch is to be injected, the needle is inserted at 
the lower border of the zygoma, 2 \ centimeters in front of the anterior 
root of the zygoma, which practically corresponds with the anterior 
wall of the external auditory canal. The needle is directed slightly 
upward to the base of the skull and a little backward, and at the depth 
of 4 centimeters reaches the nerve and its exit from the foramen. 
The injection is exceedingly painful, and should be done under nitrous 
oxide. The advantage of using this anaesthetic, rather than ether or 
chloroform, is that the anaesthesia is not so deep, and that some 
movement, or exclamation, of the patient reveals to the operator 
when the nerve has been reached, thereby making him sure of his 
point of attack. It usually results in anaesthesia in the distribution 
of the branch injected. (See Plate VI.) Where the pain has not 
been exceedingly intractable and it is hoped that more moderate 
measures will suffice a 60 per cent, alcohol solution may be used by 
injection into the upper branch as it makes its exit from the supra- 
orbital foramen, or into the middle branch as it takes its exit from the 
infra-orbital foramen. By manipulation the trochlear nerves at the 
inner angle of the orbit may be injected through the same puncture 
as that used to reach the supra-orbital nerve. Here, again, at least 
novocaine should be first introduced through the skin, but preferably 
nitrous oxide should be employed. 

Within the last few years the treatment of neuralgia by kataphoresis 
(see Part III.) has come into prominence, and consists in the use of 
some anaesthetic such as chloroform, which is applied over the part on 
a small piece of lint, and a galvanic current used through the pledget 
which is attached to the positive pole. Under these circumstances 
the anaesthetic passes through the skin and affects the nerve. 

A very useful injection in neuralgia is J to J grain (0.007-0.015) of 
morphine, but the danger of beginning the morphine habit is to be 
remembered when treating chronic cases. Sometimes acupuncture 
(see Part III.) is of service, and the surgeon may be called upon to 
stretch the nerve or to do a neurectomy. 



NIPPLES (SORE). 

Whenever the nipples become sore, so that it is impossible for the 
mother to allow the child to nurse, a solution of cocaine of the strength 
of 4 grains to the ounce (0.25-30.0) should be applied to the part and 
washed off carefully just before the child sucks. Following the nurs- 
ing, a solution of boric acid, of the strength of 20 grains to the ounce 
(1.3-30.0) of water or mucilage of acacia, may be used over the part, 
the nipple being first thoroughly dried. Where the fissures are deep 



868 DISEASES. 

and slow to heal the tip of a stick of silver nitrate may be applied to 
them with advantage. Some practitioners employ tincture of benzoin 
over the inflamed part, and glycerite of tannin is often of value. Clean- 
liness, dryness, and care of the breast previous to parturition do much 
toward preventing this condition. (See Balsam of Peru.) 

Sometimes it is necessary to use a breast-pump or nipple-shield 
before a cure can be effected. 

OBESITY. 

Whenever an excess of fat accumulates in the body, various dis- 
comforts, both mental and physical, arise, and in addition the normal 
functions of all the parts are so disturbed or interfered with that the 
continuance of health is often impossible. In many cases the deposi- 
tion of fat about the heart or between its fibres results in serious symp- 
toms; and breathlessness on exertion is produced by the obstruction 
which is offered to the free movements of the diaphragm by masses of 
omental fat, aided by the fact that the great weight and bulk of the 
body requires severe muscular effort. It is worthy of note, also, that 
a layer of fat over the body increases the vascular surface very greatly, 
and in consequence gives the heart the labor of supplying a larger 
number of bloodvessels. 

In many families there is an inherited tendency to obesity, while in 
others only certain individuals are affected. These persons are fat 
because their bodies naturally tend to the deposit of obese materials, 
in the same way that the members of one family have large bones, 
while those of another have a small frame. The etiological causes of 
obesity, outside of those just named, are numerous, but the chief one 
is overindulgence in food, probably associated with some disorder of 
the thyroid and other glands of internal secretion. 

It is not out of place to state exactly what overindulgence in food 
means. Every individual is a law unto himself in regard to the amount 
of food which is ingested and consumed. One often sees large, power- 
ful, wiry men, who eat little, stand beside others, not so powerful or 
large, who eat excessively, and who apparently do not suffer from 
indigestion in consequence. Neither of these groups becomes ex- 
cessively fat, because one represents a grate which burns its fuel so 
that there is no waste, while the other resembles a grate in which there 
is always a residue of unburnt coal which is cast out with the ashes 
as effete matter. As different engines of the same build require varying 
amounts of coal, so do different men assimilate different amounts 
of food. No stated amount of food can be set down as a man's daily 
portion until his case is carefully studied, but it is important to remember 
that the quantity of food is generally in direct ratio to the severity of 
the toil, and that a man who loiters about a club or ' 'takes life easily" 
often eats more than a day laborer — of far richer foods, too — and 
wonders why he gets stout. In nearly every case of obesity not depend- 



OBESITY. 869 

ent upon gross disorder of nutrition overindulgence in food is the cause. 
To some this may seem absurd, and the patient will say that he eats 
just enough to keep him from feeling empty between meals; but 
this does not alter the case in the least. The proper amount of food 
for a man is not what his appetite or gastric viscus calls for, but what his 
system needs. To this further reference will be made when consider- 
ing the diet for obesity, found below. 

The very presence of fat aids in the deposition of it, for, by acting 
as a non-conducting pad all over the body, it prevents the dissipation 
of heat, and so decreases the combustion of those substances which, 
when not used for the manufacture of heat, are deposited as fat. 
Again, we find that obese persons often take alcohol with their food, 
thereby increasing the fat in their bodies; for, finding that they cannot 
digest all the substances which greediness makes them swallow, they 
take alcohol to stimulate their digestive apparatus to increased efforts 
and assimilation. Further than this, alcohol adds force to the body, 
and preserves the tissues by substituting itself for food in the oxidizing 
processes. 

We find, therefore, that three great causes are active in producing 
corpulence in many cases — namely, heredity, overindulgence in food, 
and lack of exercise, which is one of the means by which overindul- 
gence is produced; i. e., less exercise, less food needed, but often more 
eaten. 

The treatment of corpulence rests solely upon the conditions named. 
In all instances the diet is the important point for the bestowal of care. 
Reference has already been made to the fact that the needs of the system 
are the criterion by which should be determined the amount of food 
necessary to each case, not the sensations in the stomach. The use of 
coca by the natives of South America enables them to withstand 
hunger and privation, not because it gives tissue to the body, but 
because it paralyzes the sensory nerves in the stomach and relieves 
the sensation of hollowness or weakness which we are accustomed to 
overcome in this country, in the absence of food, by tightening our 
belts. Every one who has undergone severe mental or physical labor 
and missed a regular meal will remember that about the usual hour 
for the meal his sensation of emptiness may amount to nausea and 
distress, but the hour once passed he feels as strong as before until 
by prolonged toil he so exhausts his powers that the system forces 
him to eat, not so much from hunger as from exhaustion. To under- 
stand this clearly, we must recollect that the system keeps its shares 
of force in the same way as a careful speculator keeps his shares of 
stock — namely, one part in active use for speculation, the other half 
for reserve in case of need. In health the stomach begins to "feel 
hungry" as soon as the speculative shares of force are nearly used, 
in order to cause the ingestion of more food and to preserve the "sink- 
ing fund" intact. It becomes evident, therefore, that the mere pres- 
ence of hunger is purely a symptom, not an indication of the absolute 



870 DISEASES. 

necessity of food, for, if it were, the consumptive might be notorious 
for his appetite, instead of being noteworthy for his anorexia. 

The food of the patient suffering from obesity is to be cut down 
gradually, and the character of it arranged so that, though its bulk be 
great, its nutritive properties are small. Beef and other meats are 
concentrated foods containing much nourishment in a small bulk, 
while lettuce, spinach, cabbage, and nearly all vegetables, except 
roots or tubers, contain a large amount of fibre useless to the body. 
By the use of a carefully arranged vegetable diet in obesity we cut 
down the actual amount of food absorbed, and by its bulk keep the 
stomach so busy at sifting the nutritious from the non-nutritious 
materials that hunger is not felt, because another meal-time is reached 
almost before the food of the first is assimilated. We find, therefore, 
that the diet for the reduction of corpulence should consist chiefly of 
bulky vegetables, but not too exclusively of any one article or set of 
articles. Heretofore it has been thought that proteids (meats, eggs, 
etc.) should be used to take the place of all hydrocarbons or carbohy- 
drates (fats, starches, and sugars), but this is not physiologically cor- 
rect, as both forms of food are always needed for health, and it has 
been found that proteids may be converted into fats in the body. The 
following bill of fare will be found of service in the treatment of obesity. 

Breakfast: One or two cups of coffee or tea, without milk or sugar, 
but sweetened with a fraction of a grain of saccharin. Three ounces 
of toasted or ordinary white bread or 6 ounces of bran bread. Enough 
butter may be used to make the bread palatable— not more than 1 
ounce. Sliced raw tomatoes with vinegar or cooked tomatoes without 
any sugar or fats. This diet may be varied by the use of salted or 
fresh fish either at breakfast or at dinner. This fish must not be rich 
like salmon or sword-fish, but rather like perch or other small fish. 

Noon meal (dinner): One soup-plate of bouillon, consomme, 
Julienne, or other thin soup, or oyster broth, followed by one piece 
of the white meat of any form of fowl or a small bird. Sometimes 
a small piece, the size of one's hand, of rare beef or mutton, but no 
fat, may be allowed, and this should be accompanied by string-beans, 
celery (stewed or raw), spinach, kale, cabbage, beans, asparagus, 
leeks, and young onions. Following this, lettuce with vinegar and a 
little olive oil (to make a French dressing), a cup of black coffee or one 
of tea, and. a little acid fruit, such as sour grapes, tamarinds, and 
sour oranges or lemons, may be taken, and followed by a cigar or 
cigarette. 

Supper should consist of one or two soft-boiled eggs, which may also 
be poached, but not fried, a few ounces of bran bread, some salad and 
fruit, and perhaps a glass or two of light, dry (not sweet) wine, if the 
patient is accustomed to its use. 

Before going to bed, to avoid discomfort from a sensation of hunger 
during the night, the patient may take a meal of panada, or he may 
soak Graham or bran crackers or biscuits in water and flavor the mass 
with salt and pepper. 



OPHTHALMIA. 871 

The reduction of diet is generally best accomplished slowly, and 
should be accompanied by measures devoted to the ultilization of the 
fat present for the support of the body. Thus the patient should not 
be too heavily clad, either day or night, should resort to exercise, 
daily becoming more severe, and should not drink freely of water, 
unless sweating is established sufficiently freely to prevent the accumu- 
lation of liquid in vessels and tissues. 

Very often a cold bath will, by its dissipation of heat, cause destruc- 
tion of fat, which will be burnt up in the body in the manufacture of 
heat-units to maintain the temperature; and if the patient is not too 
anaemic and stands this exposure to cold well, the bath should be 
repeated each day or a Turkish bath followed by a cold plunge used 
instead. 

The bowels should be kept active by the use of laxative fruits or 
purges, but if liquids taken in drink are not eliminated rapidly, saline 
purges are useful, since if the bloodvessels are engorged, the circula- 
tion in the capillaries is slow and a deposit of fat is apt to result. 

Where proper exercise is impossible the rest cure, with massage, 
electricity, passive exercise, iron and arsenic, and an absolute skimmed- 
milk diet, may be resorted to, particularly in those persons known as 
"fat ansemics," who have not enough red corpuscles in their blood to 
carry sufficient oxygen to the tissues to complete oxidation. 

So far as medication is concerned, the value of the thyroid gland in 
some cases is not to be forgotten. (See Thyroid Gland, Part II.) 



OPHTHALMIA (SYMPATHETIC). 

This term is applied to an inflammation of the uveal tract (iris, 
ciliary body and choroid) of one eye, due to the effects of a similar 
inflammation of the other eye. 

The most usual lesions which produce this affection are wounds in 
the ciliary region, passing through "the danger zone," about one- 
fourth of an inch wide, surrounding the cornea, beneath which lies the 
ciliary body, followed by an infective iridocyclitis; retained foreign 
bodies within the globe, which have created an iridocyclitis ; perforating 
wounds or ulcers, with prolapse and incarceration of the iris, or scars 
involving the ciliary body. It occurs more commonly in children 
and young persons than in those of maturer years, but no age of life is 
exempt. The eye primarily thus injured is called the "exciting eye;" 
the fellow eye, to which the inflammation is transferred, is called the 
"sympathizing" eye. 

The affected eyes should be treated with atropin, as in all cases of 
iritis, unless there is rise of tension. Mercury internally, or by inunc- 
tion, is usually advocated and should be tried, but the remedy which 
does the most good is salicylate of sodium in very large doses, as much 
as 1 grain (0.065 gm.) of this drug daily for each pound of body weight.' 
As these large doses cannot always be borne, 60-100 grains (3.9-6.5 



872 DISEASES. 

gm.) per diem may be given. In place of the salicylate, aspirin may be 
employed in very large doses. Salvarsan and neosalvarsan have been 
used with good effect. Other drugs which have been recommended 
are atophan (40-60 grains or 2.6-3.9 gm. daily), and benzosalin in full 
doses. Prophylaxis comprises the treatment of the eye originally 
injured, and preventive enucleation, if treatment is unavailing and 
sympathetic ophthalmia is threatened. 



PERICARDITIS. 

If the case be sthenic and is seen early, and the heart is overacting, 
five to ten leeches or several small fly blisters should be placed over 
the prsecordium. An ice-bag placed over the prsecordium not only 
relieves the pain, quiets the circulation, and reduces the temperature, 
but also acts favorably in modifying the severity of the inflammation. 

Where the case passes from the acute stage of inflammation to 
that in which effusion takes place, or if the patient is already de- 
pressed by illness, the treatment becomes supportive if the circulatory 
system shows signs of failure. The friction-sounds of the first stage 
are now lost, and the heart-sounds may be feeble or muffled by reason 
of the effusion present. Digitalis, alcohol, or caffeine may be used if 
the heart shows signs of failure; but when digitalis is used its influence 
should be carefully watched, since the employment of this drug pro- 
duces a very full diastole or dilatation of the ventricles, and these are 
already cramped for space in which to dilate by reason of the exudate 
which has entered the pericardial sac. If the effusion is sufficient to 
endanger life, it should be tapped and aspirated very gradually. Often 
it is best to explore with a long coarse needle attached to a hypodermic 
syringe in order to be sure that there is fluid, but the greatest care must 
be taken that the heart is not wounded. Some authorities hold that 
the danger of wounding the heart is so great that it is best to make an 
incision. The best places for making the puncture are the fourth or 
fifth intercostal space, very close to the left edge of the sternum, or 
in the fifth right interspace, close to the sternum, but West advises the 
fifth or sixth interspace to the left of the nipple because the effusion 
pushes the heart upward and the lung to one side. If the tap is "dry" 
and the physical signs of effusion are positive, the posture of the patient 
should be changed and another trial made. Often a blister over the 
prsecordium is of service in aiding absorption. Should pus be present, 
free drainage must be established by means of an incision, and it may 
be necessary to excise the sternal end of the fifth rib on the left side. 

When an old pericarditis causes adhesions in such a manner as to 
seriously interfere with cardiac action the operation of cardiolysis is 
to be considered. 



PERITONITIS. 873 



PERITONITIS (ACUTE). 



The views of the best minds in the medical profession concerning 
the treatment of peritonitis have changed radically in the last few 
years, chiefly through the advances made in abdominal surgery and 
bacteriological research. These opportunities for study have shown 
that peritonitis never arises as a strictly primary condition, but is 
due in every case to the infection of the peritoneum by micro-organ- 
isms, benign or malign, which originally are found in the intestines 
or other portions of the abdominal viscera. Even when peritonitis 
follows directly upon injury, the actual cause of the pathological 
process is the escape of micro-organisms through the devitalized wall 
of the intestine, and the severity of the attacks depends in turn upon 
the vital resistance of the patient, the virulence of infection, and the 
rapidity with which a plastic exudate is thrown out to encapsulate 
the inflamed area. 

It is not possible in this article to discuss the facts now known in 
regard to the etiology and pathology of acute peritonitis. Suffice it 
to state that the bacillus coli communis found normally as a benign 
inhabitant of the intestine becomes at once, on entrance into the 
peritoneal cavity, malignant and capable of producing rapidly fatal 
peritonitis. Nor is actual rupture of the bowel or appendix vermi- 
formis necessary for this infection, since it has been shown that this 
germ rapidly migrates through the bowel-wall as soon as it becomes 
inflamed or congested in all its coats. Streptococci and staphylo- 
cocci, finding access to this cavity, also produce violent inflammation. 
It has been found that the peritoneum will destroy many infecting 
germs if its vitality is not impaired, but if it is impaired, even a mild 
infection gives rise to severe inflammation. 

Having learned, then, that acute peritonitis is always secondary to 
some local cause or to some general infection, the first thing for the 
therapeutist to do is to determine what the provoking agent is, in order 
that his treatment may be directed against the cause rather than the 
effect. This cause is now known, in the great majority of cases, to 
be Appendicitis (which see), the inflammatory process being spread 
by infection from this source. In women it is not uncommonly due 
to more or less obscure pelvic disease; or, again, it may arise from 
abscess and other severe diseases of the liver, spleen, pancreas, or 
stomach. Finally, it should never be forgotten that intestinal obstruc- 
tion and perforation are causes of peritonitis. The physician may 
rest assured that if he cannot find the provoking cause, it is his own 
fault, and he is not to decide that the case is purely idiopathic. 

Having found the cause, treatment is, of course, to be at once insti- 
tuted, and is medical or surgical — more commonly the latter than the 
former — since nearly all the exciting causes of this disease are at most 
only palliated by medicinal treatment, while they can sometimes 



874 DISEASES. 

be removed by surgical interference. Fortunately for those who can 
only obtain medicinal treatment, Nature does much to aid in producing 
a cure in many cases by limiting the disease through its localization 
by walls of lymph, so that many cases of peritonitis recover without 
active medicinal or surgical care. In the pelvis this localization of 
the process very often takes place. 

If the trouble arise in the appendix vermiformis, this condition 
may be treated in its early stages by the means suggested in the article 
on Appendicitis. In many cases requiring operation it is performed 
too late through the hesitancy of the patient, his friends, the physician, 
or even of the operator himself. If the local trouble does not seem to be 
spreading and the patient's general condition is favorable, operation 
should be postponed until a state of quiescence is reached, when the 
prospects of recovery from operative interference are better. If there 
is reason to believe that an abscess has ruptured into the peritoneal 
cavity, or if perforation of the bowel is suspected, or shown to be present 
by severe general symptoms of widespread peritoneal involvement, 
operation should be resorted to at once. 

In deciding the question, however, as to whether a case of peritonitis 
requires surgical interference, the physician at the present time is in an 
unfortunate position. There can be no doubt that there are many 
records in medicine which prove most conclusively that lives have been 
saved through operative interference which would have been undoubt- 
edly lost had the surgeon not come to the rescue. On the other hand, 
there are cases in which a fatal result has followed an operation, and in 
which the physician has bitterly reproached himself that he consented 
to surgical interference, for as he looked back over the case he per- 
ceived that the operation distinctly aided in causing the loss of life. At 
the present time each case must be decided upon its individual merits, 
and the physician or surgeon in giving advice to the family in regard 
to a well-developed case of peritonitis should always be careful to let 
them understand distinctly that the condition of the patient is most 
alarming, and the chances of life poor whether the treatment be medi- 
cal or surgical, since in many instances neither form of remedial 
measure can possibly produce good results. In other words, the 
relatives should clearly be made to understand that whether medicinal 
measures or surgical procedures are resorted to, the patient has only 
a fighting chance. 

This work is not the place for the consideration of the surgical 
procedures to be followed, but it may be stated that in septic peritonitis 
in many cases it is a question of operation with probable death, or no 
operation with certain death. In obscure cases of general peritonitis, 
where the cause of the disease cannot be detected by ordinary methods 
of diagnosis, the writer believes that exploratory incision should be 
done which may reveal a perforated or gangrenous appendix, or a per- 
forated duodenal ulcer or gall-bladder. 



PERITONITIS. 



875 



Fig. 137. 



Fig. 138. 




GLASS "U" TUBE 



!000..y 



~1 



Aside from the surgical treatment, which is an absolute essential in 
many cases of peritonitis, we have at hand medicinal methods which 
are of some value early in the 
attack and where operation is re- 
fused or considered inadvisable. 
The first of these is the use of 
opium, given until the pain is 
partly decreased. The patient 
should never be so narcotized as 
to have no pain on abdominal 
palpation or be unable to answer 
questions. On the other hand, it 
should be remembered that cases 
of peritonitis often bear large doses 
of opium without much effect. 
The dose should be pushed until 
the desired effect is obtained, and 
not be measured in grains. (For 
the proper use of opium, see Ap- 
pendicitis.) 

An ice-bag or a turpentine stupe 
may be put over the area origi- 
nating the trouble. Should vom- 
iting be a pressing symptom, it is 
best controlled by the use of 2 



Coupling of glass to 
be put in rubber tubing 
so as to count the drop- 
rate, with compressor to 
regulate flow. (Mein- 
ecke.) 




Proctoclysis apparatus, consisting of fountain syringe, large rubber 
tube, and vaginal hard-rubber or glass tip. 



grains of acetanilide given every two or three hours on brandy and 
ice. Medication is best carried out by the hypodermic needle or the 
rectal injection. The thirst in many cases of peritonitis is excessive, 
and may be relieved by Murphy's method (see below). Gastric lav- 
age is often advantageous. 

Post-operative, or septic, peritonitis, which for any reason is inoper- 
able, is best treated by Murphy's method of saline irrigation by the 
rectum. This consists in placing and maintaining the patient in a 



876 



DISEASES. 



Fig. 139. 



semirecumbent position and then introducing slowly, drop by drop, 
normal salt solution at 102° F. The salt solution is placed in a Wolff 
bottle, which, in turn, is immersed in a water-bath, the tempera- 
ture of which is carefully watched. 
Better still, the apparatus in Figs. 
137 and 138 may be employed, 
the salt solution being frequently 
renewed. In other instances, 
where a regular apparatus for 
this form of enteroclysis is not 
at hand, the scheme devised by 
Dr. S. Newman, of St. Louis, may 
be resorted to. (See Fig. 139.) 
By his plan an ordinary stand, 
such as is used in pharmaceu- 
tical or chemical laboratory, with 
brackets carrying two funnels, is 
employed. By means of a piece 
of rubber tubing attached to the 
upper funnel, which tubing can 
be compressed by a pinch-cock, 
the rapidity of flow from the 
upper funnel can be controlled. 
By means of a rubber tube at- 
tached to the lower funnel the 
salt solution is conveyed to the 
rectum of the patient, and the 
fluid is heated by placing the 
bulb of an incandescent lamp in 
the lower funnel in such a way 
that it is in part submerged, and 
the fluid from the upper funnel 
falling upon it becomes heated. 
If the saline fluid in the lower 
funnel becomes too hot, the elec- 
tric current can temporarily be 
turned off from the lamp. 
It is essential that the flow of saline solution through the catheter 
shall be controlled by means of some pinch-cock or other device which 
will allow the fluid to dribble into the bowel, since if it flows too fast the 
bowel will become angry and expel it instead of absorbing it. Thirty 
drops to the minute is the usual maximum. 

Murphy advised the employment of a rectal bulb or tip (see Fig. 
140), provided with a shoulder, which enables it to be retained in the 
rectum with ease. This rectal bulb, has a central canal through which 
a soft-rubber catheter is passed, which catheter carries the saline solu- 
tion. In those instances in which the rectal bulb causes too much 




Newman's apparatus for proctoclysis. 



PERITONITIS. 877 

dilatation of the sphincter, and so induces irritation, the ordinary 
vaginal douche-tip, which is supplied with the commonly employed 
fountain syringe may be used in its stead. It is exceedingly im- 
portant that the strength of the saline solution shall be slightly 
hypotonic (0.5 per cent.) instead of that of the tissues — 0.8 or 0.9. 
Stronger solutions will abstract liquid from the tissues instead of 
being absorbed. The vessel holding the fluid should not be ele- 
vated more than 6 or 7 inches above the anus, as a very slow 
delivery of the fluid is desirable. The irrigation is continued for 
several days in certain cases and the large amount of fluid which 
is absorbed by the bowel is remarkable. Some patients take as 
much as 16 pints in twenty-four hours. The theory of this method 

Fig. 140. 



Self-retaining tips on catheter, showing how adjustment can be accomplished by merely draw- 
ing catheter through to des red length. 

of treatment is that a reverse current of lymph in the peritoneal 
lymphatics takes place, so that instead of absorption occurring from 
the peritoneal surface, the openings of the lymphatics pour out fluid 
which escapes through the drainage-tube or tubes which are inserted 
through the abdominal wall. There is no doubt of the therapeutic 
efficiency of this method, which frequently saves otherwise hopeless 
cases, but there is doubt of the correctness of this explanation of its 
usefulness. The posture of patient aids in limiting the exudate to the 
pelvis. 

The tympanites,, which may be a prominent symptom, may be 
relieved in some cases by the use of the rectal tube or by injections 
into the bowel of milk of asafoetida or turpentine emulsion. (For 
formula, see Typhoid Fever.) 

PERITONITIS (CHRONIC). 

Chronic peritonitis is very apt to be circumscribed and to exist in 
connection with chronic appendicular trouble or in females in associa- 
tion with diseases of the organs of generation. The most diffuse and 
curable form of the disease is that known as tubercular peritonitis, in 
which cures have been safely reached through abdominal incision with 
or without drainage or the dusting in of iodoform. Of all forms of 
organic disease affecting the abdominal area and of a chronic type, none 
offer such favorable results to the physician and surgeon as does this, 
and operation ought always to be advised and urged upon the patient 



878 DISEASES. 

most strenuously, provided that type of the disease is present in 
which ascites and abdominal distention are marked. In that form 
characterized by matting of the coils of intestines and of the omentum, 
operation cannot give such good results. Care should be taken, how- 
ever, to separate the subacute or chronic process termed tubercular 
peritonitis, from the malignant and acute form called tuberculosis of 
the peritoneum, which is often only a manifestation of a general miliary 
infection. 

PLEURITIS, OR PLEURISY. 

The treatment of the acute form of this disease in its early stages is 
identical with that of other inflammatory affections. In other words, 
the use of a few doses of tincture of veratrum or aconite, to bleed 
the man into his own bloodvessels, is to be resorted to if the patient 
is seen in the very earliest stages and has a tense, bounding pulse. If the 
circulation is not bounding, these drugs should not be used. 

When the pain from the pleurisy is excessive and the respiratory 
movements greatly increase the discomfort, strapping the chest-wall 
may be resorted to. This is done for the purpose of immobilizing that 
side of the chest. The straps should consist of adhesive plaster, two and 
a half inches wide, and should be long enough to reach from the middle 
line of the vertebrae to the sternum or a little beyond its middle line. 
They should be applied tightly during expiration, slightly overlapping 
one another at a right angle to the spine, and not in the line of the ribs 
(Fig. 141). m 

The old idea that pleurisy was usually due to cold rather than to an 
infecting micro-organism led to the practice of enveloping the chest 
in poultices. These soil the clothing, speedily get cold, and become 
very uncomfortable. They have been supplanted almost entirely by 
the cotton jacket, which is much better. It consists of one or two 
thicknesses of carded cotton basted inside a thin undershirt, as fur is 
placed in a fur-lined coat. On the outside of the shirt oiled silk should 
be basted. By using this we envelop the chest in a warm poultice, 
because the heat of the body keeps the cotton at the proper tempera- 
ture, while the oiled silk, by preventing evaporation of the moisture 
exhaled from the skin, soon causes the cotton to become moist as well 
as warm. Even the cotton jacket is losing its popularity, as the fever 
of the patient makes a hot jacket almost unbearable and it does little 
real good. Further, its removal is very apt to result in exposure 
to cold. The author never uses either of these dressings. 

When the pleurisy has fully developed, other lines of treatment are 
needed. The cardiac sedatives should be stopped as soon as the quiet- 
ing of the circulation has been accomplished. If the pulse becomes 
weak and the system is depressed, stimulants in the form of alcohol or 
digitalis are needed, and special care must be devoted to the condition 
of the exudate in the pleural space. 

The physical signs at this time consist in flatness on percussion 



PLEURITIS, OR PLEURISY. 879 

over the^ lower portions of the chest, which area of flatness generally 
varies with the change in the position of the patient from the erect 
to the recumbent position, unless the effusion is sacculated. Blowing 
or bronchial breathing at the apex of the lung, when this organ is 
compressed upward by the fluid beneath it, is often heard. If the 
effusion is on the right side, the apex beat of the heart is apt to be 
displaced to the left. If it is on the left side, there is obliteration of 
Traube's semilunar space, which is a spot at about the level of the 
sixth and seventh ribs anteriorly below the nipple, where there is 
usually a tympanitic note on percussion. 



\ 



Fig. 141. 




£$. 



Showing the overlapping of the adhesive strips in strapping the chest for painful pleurisy. 
The strips extend too far to the patient's right 

If the effusion is sufficiently large to cause marked dyspnoea 
or reaches to the third interspace anteriorly, it should be removed 
by aspiration. When the effusion is not causing dyspnoea, or other 
evil symptoms by reason of pressure, the physician should allow suf- 
ficient time for recovery to occur; as, for example, a week or ten 
days, during which interval the system will in many cases remove 
the fluid by natural processes of absorption. If after this time has 
elapsed the quantity of fluid remains unchanged resort must be had 



880 



DISEASES. 



to aspiration of the liquid. Purges ought never to be employed so 
freely as to weaken the patient, and in most cases they are futile be- 
cause the pleural surfaces are covered by a fibrinous exudate which 
prevents absorption. In his own practice the author never uses these 
drugs, but resorts to aspiration. 

In cases in which it is desired to attempt the removal of a pleural 
effusion by the use of purgatives and diuretics, and it is doubtful if 
absorption can go through the pleura, we may inject 5 grains (0.3) 
of methylene- blue into the affected pleural cavity, give the purgative, 
and examine the urine for the blue. If it is eliminated, absorption 
is possible; if not, the removal of the fluid by the aid of purgatives is 
probably impossible. 

In order to cause proper expansion of the lung after convalescence 
is begun, chest exercises should be used (see Part III) and wash- 
bottles may be employed, as are shown in Fig. 142. 

There is no danger in aspiration if it is properly performed. The 
best place to insert the needle is the sixth or seventh interspace in the 
middle axillary line. Care should be taken that the needle is aseptic; 
that the skin at the point of puncture is well cleansed; and that the 
exhaust-pump is working well. All the liquid should not be with- 
drawn at one sitting. Often the withdrawal of a portion of it will 
result in the natural absorption of the quantity which is allowed to 
remain in the chest. 

During this stage of effusion blisters have been largely used to aid 
absorption of the fluid which is present, but they are not of great 



Fig. 142. 




Arrangement of bottles for promoting lung expansion. 

service. When used they should be applied in the form known as fly- 
ing blisters. (See Cantharides, Part II.) It is to be remembered that 
blisters are, as a rule, contraindicated in the case of children, because 
of the pain and irritation they produce. If a pleural effusion in the 
chest of a child is not absorbed by natural processes, it is best to 
aspirate it. 
If the fluid is purulent, it must be removed by making an intercostal 



PNEUMONIA. 881 

incision and draining the abscess cavity, although if the displacement 
of the heart is greaF we should first aspirate to relieve pressure and 
operate afterward. 

In children, except in very chronic cases, it usually suffices to intro- 
duce a large drainage-tube through a canula, remove the canula, make 
the tube fast with a safety-pin and an adhesive strip, and attach a short 
piece of glass tubing so that the flow can be watched. To this glass 
tube is attached a long rubber tube running to a bottle below the bed. 
By this means drainage is maintained, and a cure results without the 
hardship of excising a rib. If the tube gets stopped up, it can be 
opened by milking it or by direct suction with a syringe. 

PLEURODYNIA. 

This condition, being one of intercostal myalgia or neuralgia, should 
be treated according to the directions given under the headings of 
Neuralgia and Counterirritation. 

PNEUMONIA. 

Pneumonia is a term loosely applied to two different forms of 
disease — namely, that acute infectious process due to an infection by 
micrococcus lanceolatus and called croupous pneumonia; and that 
form following, as a rule, some other disease which has exhausted the 
patient's strength and due in some cases to various forms of infection, 
namely catarrhal pneumonia. These two distinct diseases have been 
confused by the common term pneumonia, and yet are very different 
conditions as to their pathology and treatment. 

There is, however, one factor in treatment common to both classes, 
whether they occur in children or adults, namely, plenty of fresh air. 
It is essential in adults. In well-appointed hospitals croupous pneu- 
monia is treated out of doors, as in an open shed or on the roof, with the 
result that the mortality is far less than in the best ventilated wards. 
A few hours of fresh air will often produce remarkable changes in the 
patient's condition. The open-air plan is indicated in the croupous 
type. When bronchopneumonia is present it is of questionable value, 
particularly in children or asthmatics. 

Croupous Pneumonia. 

The treatment can be divided into that devoted to the stage of 
onset, the stage of consolidation, and the stage of absorption of the 
exudate and convalescence; and it will be governed by the state of the 
patient's pulse, the sounds of his heart, and his general condition as 
to strength, as well as the degree of respiratory embarrassment which 
is present. There can be no routine treatment of croupous pneumonia; 
each case must be a law unto itself, and there is no such thing as the 
depletant treatment to be advocated on the one hand, not the stimu- 
56 



882 DISEASES. 

lant treatment to be lauded on the other. (For Antipneumococcic 
Serum see article on Antitoxin, Part III.) Further than this, it must be 
remembered that as croupous pneumonia is an acute infectious disease 
the patient may die, not from pulmonary consolidation nor cardiac dis- 
tention, but from the malignancy of the infection. One man with an 
entire lung consolidated may have slight evidences of general infection 
or toxaemia; another with a small area of lung involved may be over- 
whelmed by toxaemia within a few hours. For this and other reasons 
all cases of croupous pneumonia may be divided into three groups 
— those that are doomed to death by the malignancy of the infection, 
those that are but slightly ill by reason of mild infection, and those 
which are between these two extremes of severity and need careful 
medical aid to accomplish recovery. The first class die, do what we 
will, the second class get well almost without help, the third need 
all the help possible to survive. It is to this last class that our treat- 
ment must be chiefly directed. 

It is of vital importance to remember that the patient does not need 
medicine simply because he has croupous pneumonia. 

The fact must not be lost sight of that croupous pneumonia is 
often a terminal infection superimposed upon nephritis or some other 
malady. The primary disease must, therefore, be considered in all 
plans of treatment. 

In the very earliest stages of the disease occurring in a healthy, 
sthenic individual who has been seized with a chill followed by fever 
and a bounding pulse, with marked anxiety and nervous excitement, 
it is often proper to bleed freely from a vein in the arm to the extent 
of a pint (see Part III.). A hot foot-bath at this time will also tend to 
relieve thoracic congestion. If severe pain in the chest is present, it is 
to be relieved by moderate doses of morphine or Dover's powder. 

This depressant treatment of croupous pneumonia is, however, lim- 
ited in its application to the very beginning of the malady and to those 
persons in whom the malady is a primary disease, not a terminal in- 
fection, as it is in the great majority of cases. It is absolutely contraindi- 
cated after consolidation has taken place or if the patient is feeble. Be- 
cause of the fact that its usefulness is confined to this early stage, it can- 
not be employed in the majority of cases because the physician is not 
called until after this stage has passed. I repeat, that its use in a case 
with a feeble pulse or in one who is adynamic or feeble is absolutely 
contraindicated. Furthermore, it is not to be used if any primary 
malady, such as nephritis, is present, as this renders the case asthenic 
from the onset. 

In the majority of cases the physician is called after consolidation 
has occurred, and he must now be a watchman all the time and a 
therapeutist only when treatment is actually needed. Every patient 
who is sufTering from pneumonia does not need active treatment. A 
certain number of cases get well without treatment, and do so sooner 
than if meddlesome therapeutics hinders them. The treatment usually 



PNEUMONIA. 883 

necessary is to combat fever if it becomes excessive, to support the 
heart if it seems feeble or engorged, to keep the kidneys in a state of 
active secretion, and to see that constipation is relieved. 

How anyone can see a hepatized lung and then think that those 
remnants of barbarism, cotton jackets and poultices on the chest, are 
going to do anything else than harm the patient I cannot understand. 
There is not a reader of this book who could tolerate a hot poultice all 
around his chest as long as it takes him to read this article. There 
would be a demand for more air because the poultice oppressed him, 
although he has two good lungs and a healthy heart. If a hepatized 
lung is the local lesion resulting from a general infection, why should 
we poultice the chest in pneumonia any more than we would paint 
the abdominal wall with nitrate of silver to treat the intestinal ulcers 
in typhoid fever? 

In the treatment of the fever the physician should remember that it is 
not to be regarded as a dangerous symptom unless it rises to 105 ° F. and 
remains at this point for some hours, for in a febrile disease running 
a short course fever is not only harmless, but there is also reason to 
believe that when present to a moderate degree it is actually beneficial. 1 
When the fever persists at a point above 105° F. it should be reduced 
by sponging with cool water, active friction being used at the same time. 
(See Cold, in Part III.) There is absolutely no danger of the patient 
"taking cold," although this is generally doubted by the laity. If 
the fever has a tendency to be excessive or if the heart's action is 
tumultuous, an ice-bag may be placed over the heart, and this will be 
particularly useful if, as is often the case, there is a tendency to pericar- 
ditis. If it is desired to apply cold over a greater area of the chest 
than the prsecordium, cold compresses may be employed, but they pos- 
sess the disadvantage of being wet applications, do what we will to 
protect the bedding. The cold plunge bath is always badly borne in 
croupous pneumonia. (See Cold, in Part III.) 

The use of antipyretic drugs is not good practice. They tend to 
depress the heart, to relax the bloodvessels, and apparently render the 
patient more susceptible to his infection. 

For the support of the heart several circulatory stimulants may be 
employed. If the patient is an alcoholic and feeble, with lack of vitality 
and relaxation of his vessels, then alcohol in the form of a good whisky or 
brandy, given in water after food every three or four hours, in the dose of 
from half an ounce to an ounce is useful. Sometimes more than this 
must be given, particularly if the patient has been accustomed to the use 
of the stimulant. In most cases none is needed. 

For the laboring heart with almost empty arteries no drug com- 
pares with digitalis; and if the skin is moist or the bloodvessels 
relaxed, so that the pulse is gaseous, then belladonna should be com- 
bined with it. The writer usually gives 10 minims (0.65) of a physio- 

1 See article on The Role of Fever in the Modification of Disease, in the Therapeutic 
Gazette for February, 1896. 



884 DISEASES. 

logically tested tincture of digitalis every eight hours, with 10 minims 
(0.65) of the tincture of belladonna every four hours. (See Digitalis 
and Belladonna.) If necessary, both of these drugs may be given 
in larger dose, but usually these doses are sufficient. If the fever is 
very high, the digitalis will often have to be supplanted by alcoholic 
stimulants or strychnine for a few doses. The question as to whether 
the patient's pulse is of the proper strength is one of importance: 
very often the quiet pulse of a patient lying in bed will be taken by 
the anxious attendant as an evidence of true cardiac feebleness, when 
if the physician feels his own pulse he will be surprised to find it no 
stronger than that of his patient. A feeble apex beat, a feeble second 
sound at the second right costal cartilage (aortic valve), and an accent- 
uated second sound at the third left costal cartilage (pulmonary 
valve) will reveal the fact that active stimulation is needed, for the 
weak apex beat and the soft second (aortic) sound show that the heart 
is feeble and the arterial walls relaxed, and this means a low arterial 
pressure. Further, the accentuated second sound on the left side 
indicates pulmonary congestion and a tendency to failure of the right 
side of the heart from obstruction to the flow of blood in the lungs. 

One of the best means of determining upon the use of circulatory 
stimulants in pneumonia is the use of the sphygmomanometer. 
Gibson, in Edinburgh, and myself, in this country, have shown that 
danger arises when the pulse-rate per minute is equal to or above 
the systolic blood-pressure expressed in millimeters of Hg. Thus, if 
the pulse-rate be 90 and the pressure 140, all is well, but if the pulse- 
rate be 110 and the pressure 110, he is. gravely ill and needs active 
cardiac and vascular stimulation. If the pressure in millimeters of 
mercury falls below the pulse-rate, the condition is usually desperate. 

In many instances, however, the low pressure is not so much the 
result of weakness of the heart muscle but is present because the 
vessels are relaxed. In such a case the heart beats hard and fast in an 
effort to fill the vessels and becomes feeble more from fatigue than 
from toxsemia. The heart does not need digitalis to make it work 
harder at this time but its strength will be conserved if by the use of 
atropine, strychnine, caffeine or camphor the blood-pressure can be 
raised by restoring vascular tone. An estimation of the diastolic 
pressure and the pulse-pressure will guide the physician better than an 
estimation of the systolic pressure. 

Should the action of the heart become labored, the jugular veins 
distended and pulsating, and the radial pulse weak, while the face is 
cyanotic, then free venesection (Part III) is to be practised. It will 
sometimes save an apparently desperate case. Digitalis in the presence 
of this condition is not rapid enough in its effects. 

Should collapse develop, strychnine (see Nux Vomica, Part II) 
should be given in full dose hypodermically ■£§ to T V grain (0.003- 
0.006), and with it, if the skin is moist or sweating, y^- grain of atropine 
(0.0006), and both these drugs should be repeated in an hour if needed. 



PNEUMONIA. 885 

At the same time it is well to give 1 drachm (4.0) of aromatic spirit of 
ammonia every two hours in cold water or 1 drachm (4.0) of spirit of 
ether in cold water every hour. Oxygen inhalations may be used at 
this time with benefit, particularly if cyanosis is marked. (See Oxygen 
and Shock.) 

Should crisis come on at this time, active supportant treatment, such 
as that just described, will be needed. Many patients die in crisis for 
the want of active stimulation. 

A point which I wish to emphasize is the error of writing prescrip- 
tions for a pneumonia patient and having them continued for days at 
a stretch. With the possible exception of belladonna, which is used 
to prevent vascular complications from suddenly arising, I have 
never seen any case of pneumonia which needed the same remedy, 
in the same dose, day after day. The skilled physician will fit his drug 
and his dose to the needs of his patient at each visit, for, like a captain 
of a ship, he cannot control the storm, but only handle his vessel. 
The captain of a ship who leaves the bridge with written orders to the 
helmsman at 10 o'clock in the morning and does not appear on deck 
again for twenty-four hours is courting disaster. The doctor who tells 
a nurse to use full doses of active remedies every few hours for the next 
twenty-four hours or for days is almost equally courting disaster. 
If the man needs stimulation he needs it actively in one or two doses. 
He rarely needs it again and again and again, unless he is in such a 
desperate state that the physician should stand by him to reach 
an accurate estimation of his condition from hour to hour. He may 
badly need help occasionally, but not all the time. A few good-sized 
doses of digitalis are often wise, but its persistent use is usually unwise. 

Nervous excitement with insomnia, if excessive, should be combated 
by small doses, J to J grain (0.008-0.015), of morphine, given in the 
early evening by hypodermic injection, or, rarely, by 5- to 10-grain 
(0.35-0.65) doses of medinal. 

The secretion of the kidneys is best maintained by the use of some 
alkaline diuretic, such as sweet spirit of nitre and citrate of potassium, 
and if necessary a little gin may be given to support the heart and aid 
in maintaining renal activity. 

Expectorants in either type of pneumonia are never useful until 
the stage of resolution is well developed, if then. They cannot do 
good and they upset the stomach. There is nothing to spit up. 
Resolution takes place by the development of autolytic substances 
and we cannot hurry it. 

Having detailed this treatment of the second stage, that for the 
third stage is to be considered. 

It must be remembered that in most individuals the process of 
repair is carried out best if the efforts of nature are not meddled with. 

I wish to sound a note of warning against the use of iodides in cases 
of delayed resolution. The processes of nature are best suited to the 
removal of the exudate in the vesicles of the lung. The iodides may 



886 DISEASES. 

hurry these unduly, and may in the general process cause an absorp- 
tion of some old inflammatory mass which has walled off and rendered 
innocuous an old tuberculous deposit. In cases in which delayed 
resolution is present, and the physician is tempted to hurry it by the 
use of the iodide, he too often finds that the delay is not due to the 
remains of a frank pneumonia, but is the result of a terminal or coin- 
cident infection by other organisms, and the officious interference of 
the physician when nature is endeavoring to produce good results may 
be followed by disaster. Not rarely so-called delayed resolution is 
really an empyema or an interlobar empyema. 

First and foremost for the relief of any associated bronchitis stands 
the chloride of ammonium, a drug which acts most happily in aiding in 
the loosening of the cough and secretions. Its only disadvantage is its 
salty taste, which in many cases renders it disagreeable to the patient, 
while its irritant properties may disorder the action of the stomach, 
although if this organ is depressed and atonic this drug often improves 
its condition. This drug may be given in compressed tablets, or, what 
is far better, in such a mixture as here follows : 

R — Ammonii chloridi .' 3ij (8.0). 

Fluidextracti glycyrrhizae f oij (8.0). 

Aquae destillatae fgij (90.0).— M. 

S. — Teaspoonful(4.0) in water every four hours during the day. 

If the cough be in excess of the expectoration — that is, if the cough 
often fails to bring up phlegm and is due to tickling or irritation — it 
may be relieved by the addition of a little morphine to this mixture, 
as follows: 

1$ — Morphinae sulphatis gr. j vel gr. ij (0.06-0.12). 

Ammonii chloridi 3ij (8.0). 

Fluidextracti glvcvrrhizse . . . . f 5iv (16.0). 

Aquae destillatae ." fSvj (180.0).— M. 

S. — Dessertspoonful (8.0) every four hours in water. 

If much more morphine than this is used, it will tend to stop secretion. 

When the chloride of ammonium fails to act favorably, the car- 
bonate may be called into use for its local and circulatory action, and, in 
addition, the bromide of ammonium may be employed to allay the cough 
if morphine cannot be used. The following prescription is valuable: 

1$ — Ammonii chloridi 5j (4.0). 

Ammonii bromidi 5j (4.0). 

Ammonii carbonatis 3j (4.0). 

Fluidextracti glycvrrhizae fSiij (12.0). 

Aquae destillatae f gvj (180.0).— M. 

S. — Dessertspoonful (8.0) every four hours in water. 

In other cases heroin may be given in the dose of T V grain (0.005) 
every eight hours to control excessive cough. 

(For other remedies for this stage see Bronchitis.) 

It must be borne in mind that the effect of expectorant drugs upon 
the pneumonic process itself is very slight, and that they are not to be 
given unless bronchial secretion is present in excess. 



PRURITUS. 887 

Nutritious broths, milk, and, if necessary, predigested foods, should 
be given with even greater regularity than medicine would be given,, 
from the beginning to the end of the attack. 

The problems in a given case are as follows: 

1. Has the patient croupous pneumonia ? 

2. If so, what is his general state ? 

3. Are the heart, kidneys, and vessels primarily diseased ? 

4. Does he need any other treatment than rest in bed and good 
nursing ? 

5. If so, what does he, that individual, need ? 

6. Does he need stimulation, sedation, elimination ? 

7. If he needs stimulation, does he require it right along, or only at 
the moment ? When we eat we don't eat all the time, day after day, 
but only when we need food. 

8. As to all drugs follow Cromwell's motto, "Trust in God, but 
keep your powder dry." Don't give drugs all the time, but use 
remedies when needed fearlessly, and all the more advantageously 
because they have not been used before. 

Catarrhal Pneumonia. 

The main difference in the treatment of catarrhal pneumonia in 
distinction from the treatment of croupous pneumonia lies in the fact 
that first, last, and all the time the treatment is to be stimulant in its 
character if any treatment other than rest in bed is resorted to. Catar- 
rhal pneumonia usually arises out of a severe bronchitis or is superim- 
posed upon some exhausting disease which has sapped the vitality. 
Toward its close expectorants are even more useful than in croupous 
pneumonia, and every care should be taken that the catarrhal pro- 
cess does not pass by insidious degrees into a hidden tuberculosis. 
Tubercular infection should be suspected in all cases in which recovery 
is abnormally slow. 

PRURITUS. 

Itching of the skin or mucous membranes about the openings of 
the body is a very common state, and while it may be dependent upon 
local causes, such as hemorrhoids in the case of pruritus ani, it more 
commonly is due to some systemic condition, such as debility, diabetes, 
gout, or renal disease, or other similar causes. The treatment con- 
sists, first, in the removal of the cause, and, next, in the local treatment 
of the condition. There is generally no redness or eruption, except that 
due to scratching. 

Internally, arsenic, quinine, bitter tonics, cod-liver oil, alkaline 
diuretics, or mineral waters are useful in debilitated cases, and an 
avoidance of condiments, such as mustard or pepper, is needful if the 
disease affects the orifice of the urethra or vagina. 

The local treatment of pruritus consists in the use of lotions, salves, 



888 DISEASES. 

or ointments made up of various constituents, a number of which are 
capable of acting as local anaesthetics. Very often bathing the parts with 
1 drachm of bicarbonate of sodium or of borax to a pint of cold water 
gives relief temporarily, or the following formulae will be of service: 



Or, 



ty- Phenolis . foj vel f3ij (4.0-8.0). 

Aquae destillatse . . . . q. s. ad Oj (480 mils.).— M. 
S. — Apply as a lotion several times a day. 



I£ — Liquoris carbonis detergen 1 . . . . f oij (8.0). 

Aquae destillatse . . . . q. s. ad Oj (480 mils.).— M. 
S. — Apply as a lotion. 

Or an ointment made as follows is serviceable: 

I$— Phenolis gtt. v vel xx (0.3-1.3). 

Adipis benzoinati gj (30.0). 

Petrolati 3j (4.6).— M. 

S. — Apply as an ointment. 

In other cases 10 to 20 minims (0.60-1.3) of chloroform may be 
used in place of the phenol. 

Still another formula is as follows : 



1$ — Hydrargyri chloridi mitis 



oj (4.0) 



Phenolis gr. xxx (2.0) 

Picis liquidae foj (4.0) 

Mentholis gr. xv (1.0) 

Zinci oxidi oij (8.0) 

Adipis lanse hydrosi oij (60.0). — M. 

Ft. unguentum. 
S. — Apply with gentle rubbing to the parts twice a day after cleansing 
them. 

The injection into the rectum of about 2 ounces (60.0) of fluidextract 
of hydrastis night and morning may also be advantageous. 

Cocaine may be painted over the parts, but it should rarely be used 
in ointment, as fats prevent its acting effectively. It should also be 
remembered that the anal and vaginal mucous membranes are so 
thick that strong solutions of cocaine are necessary to produce anes- 
thesia, and that the effects of cocaine are only temporary. Cocaine is 
useless when applied to the skin. Where the itching is very obstinate 
the parts may be painted with a solution of nitrate of silver of the 
strength of 20 grains (1.3) to the ounce (30.0) of water, cocaine having 
been previously applied to relieve the pain of the application. (See 
also article on Cold.) In diabetic pruritus vulvae, brewers' yeast, in 
the proportion of a tablespoonful to a quart of water, may be used on 
a compress to reduce the sugar, which irritates the parts involved. 

Allingham has used with advantage a piece of ivory shaped like a 
rubber nipple and provided with a circular shield. This is slipped 
into the bowel at night and serves to keep the surfaces apart. 

In cases of general pruritus baths are often of great service. They 
may consist in plain hot-water baths or Turkish baths. In other 

1 For method of preparing this liquid, see article on Eczema. 



PUERPERAL DISEASES. 889 

instances, to each bath of 30 gallons may be added \ pound of bicar- 
bonate of sodium, or 1 to 4 ounces (30.0-120.0) of borax may be used. 
When the skin is very irritated starch, 1 pound (480), or bran, 2 
pounds (960), may be added to the bath. Sometimes linseed-meal 
baths may be used. The meal is placed in hot water until the gluti- 
nous matter is set free, when it is added to the bath. One or two 
pounds (480-960) are used. In very persistent cases the patient may 
actually eat and sleep in the bath with advantage. 



PUERPERAL DISEASES. 

The diseases of the puerperium may be divided into two broad 
classes — infectious and non-infectious. The first class should be 
further subdivided into (1) those infectious diseases in which the 
point of infection has been somewhere along the parturient tract, and 
(2) those in which the infection has entered the body by some other 
channel. Under subheading 1 come all those diseases grouped 
under the generic terms "puerperal fever/' "puerperal septicaemia," 
"puerperal infection," and the like, none of which truly expresses the 
condition. If it is necessary in medical nomenclature to have a single 
term which shall denote infection of the genitalia after delivery, a word 
should be coined strictly limited in sense to mean the pathological 
conditions which result from the activity of pathogenic bacteria along 
the whole genital tract. This classification is necessary for a clear 
and systematic description of the treatment of diseases in the puerperal 
state. 

The Treatment of Infection along the Genital Tract after Labor. — 
Uterine cultures show that about 90 per cent, of the infections of the 
genital canal are due to streptococci ; but blood cultures show that many 
of these infections are local and not general, the streptococci acting 
as saprophytes on the endometrium, and not penetrating the sub- 
jacent protective layer of granulation cells. If the microorganisms 
can be destroyed and the infected, necrotic endometrium is removed, 
the symptoms of infection disappear as does the danger of systemic 
invasion. 

The writer's routine application of this principle in practice is as 
follows: If the temperature after delivery remains over 101° F. for 
twenty-four hours without evident cause independent of the genitalia, 
he washes out the uterine cavity with Lugol's solution, 2 drachms to 
the quart (2.0-1000). To ensure the entrance of the antiseptic fluid 
to the fundus and its free exit from the cervical canal an intra-uterine 
catheter is desirable. The best is Fritsch's modification of Bozeman's 
catheter. If, however, the cervical canal is patulous, as it usually 
is after labor, a catheter attached to a Davidson or fountain syringe 
answers the purpose perfectly. 

In many cases this treatment brings the temperature down to normal 



890 DISEASES. 

within twenty-four hours. If fever does not disappear within this 
time or perhaps rises even higher, the second indication must be met. 
The uterine cavity should be explored to be sure that there is no 
mass of necrotic endometrium, decomposing blood clots or fragments 
of putrefying placenta. It is obvious that this procedure is not a 
curettage of the puerperal uterus which at one time was considered 
essential but is now never resorted to, as there is danger of implanting 
infection in the uterine wall. The reaction against the former practice 
has been so great that many specialists advocate no treatment of the 
uterine cavity at all; simply the Fowler position and natural drainage. 
But it would seem sound surgical common sense to investigate the 
condition of any infected body cavity to be sure that there was no 
mass of necrotic material in it to furnish fresh nidus of infection. 
This is best accomplished by the use of the placental forceps, care 
being taken to guard the uterine wall from injury; for not only can the 
uterine muscle be perforated by an instrument in clumsy hands, but 
slight wounds of the uterine wall may be enough to inoculate the gen- 
eral system with the germs whose activity has been before confined to 
the uterine cavity, by penetrating the layer of granulation cells under 
the endometrium. 

The writer's manner of employing this plan of treatment after labor 
is as follows : 

A cleansing and disinfecting uterine douche is given in order to 
disinfect the field of operation (Lugol's solution f3ij-Oij). 

Next the placental forceps is inserted, and an effort made to grasp 
any material lying loose within the cavity or still attached to the uterine 
walls. It is usually best to repeat the manoeuvre several times until 
nothing more is brought away except a little clear blood. 

Then the uterine cavity is again thoroughly washed out. Occasion- 
ally it is necessary to repeat the irrigation for several successive days, 
but rarely the instrumental exploration and evacuation of the uterus. 
If this treatment is unsuccessful and the temperature remains elevated 
in spite of irrigation and the use of the placental forceps, one must 
assume either that general systemic infection has occurred, or that an 
inflammatory action has begun in the uterine walls, in the pelvis con- 
nective tissue, or within the tubes. In case of general infection, the 
treatment is to support the body-cells in the combat which they 
must wage with the invading microorganisms. This is best accom- 
plished by the administration of as large a quantity of nutriment as" 
the patient can stand without rebellion of the stomach or bowels, and 
the exhibition of alcoholic stimulant. Full doses of whiskey were at 
one time thought to be essential. Digitalis and strychnine are indi- 
cated by a feeble, rapid pulse. Occasionally measures are required to 
reduce an excessive elevation of the temperature, but this is best 
avoided as long as possible, for antipyretic treatment is usually depress- 
ing and ill-suited to the patient's adynamic condition. 

The use of antistreptococcic serum, streptococcic vaccines, and 



PUERPERAL DISEASES. 891 

injections of normal salt solution are important adjuvants to the treat- 
ment, which should not be neglected in a serious case. Intravenous 
injection of collargol, fixation abscess, and the injection of healthy 
human or horse serum should also be considered. With this plan 
of treatment about three-fourths of the cases of general septic infec- 
tion after labor recover. Sometimes metastasis to important organs 
occurs so early as to render all treatment of no avail. Occasionally 
septic peritonitis develops rapidly and to an extensive degree. It is in 
such cases that cceliotomy, flushing, and draining the peritoneal cavity 
occasionally save life. The physician must guard himself, however, 
from operating too early and unnecessarily. After operation, drainage 
of the peritoneal cavity is an essential feature of the treatment, even 
although the evidence of suppuration within the cavity is slight. Local- 
ized abscesses anywhere in the pelvis or abdomen indicate incision and 
drainage. In the early stages of the peritoneal infection, if the subject 
is vigorous, not exhausted by a prolonged labor or other depressing 
causes, the administration of saline purgatives in concentrated solution 
often effects brilliant results. 

The writer's custom is to give a dessertspoonful of a concentrated 
solution of Epsom salt every fifteen minutes until free evacuation of 
the bowels is secured. He has seen the temperature reduced by this 
plan of treatment from 104° F. to normal in the course of twelve hours, 
and with the reduction of temperature all the symptoms of peritonitis, 
which were well marked, entirely disappeared. 

Infection of the parturient tract may occur anywhere from the fundus 
of the uterus to the vulvar outlet; therefore, the practitioner should 
examine carefully all the lower parturient tract in order to detect, if 
possible, an ulcerated surface covered by false membrane, which if 
overlooked might be the entrance-point for a fatal infection. These 
unhealthy surfaces are best detected by the skeleton speculum of heavy 
wire. If an unhealthy, ulcerated wound is thus discovered, the writer's 
practice is to apply to it a solution of nitrate cf silver 40 to 60 grains 
to the ounce (2.60-4.0: 30). This application promotes an exfoliation 
of the unhealthy membrane and the appearance of healthy granulation 
tissue within a few days. 

The most common point of infection outside the parturient tract 
after labor is some portion of the urinary apparatus, usually the bladder. 
Parturition necessarily diminishes the vitality of the vesical mucous 
membrane by the pressure and stretching to which it is subjected. 
After labor, therefore, it is not in a condition to resist the attacks of 
microorganisms, should these in any way gain access to the vesical 
cavity. Most commonly microbes are introduced into the bladder 
by a catheter. This, however, is not necessary, as it has been demon- 
strated that they can wander from the vaginal canal through the 
urethra into the bladder. Once arrived within the bladder, the 
microbes attack the depressed bladder cells, and may invade the 
vesical mucous membrane. This is manifested by the usual symp- 



892 DISEASES. 

toms of septic cystitis — fever, pus in the urine, pain on pressure over 
the hypogastrium, and painful, frequent micturition, The dura- 
tion of these symptoms is, as a rule, not very long. The fever sub- 
sides and the symptoms of cystitis disappear. After an interval 
of some days, however, there is again a sharp outbreak of fever, 
with pain in the region of the kidneys, the reappearance of pus, or at 
least of numerous bacteria, in the urine, and a marked leucocytosis. 
This indicates a septic infection of the pelves of the kidneys after the 
micro-organisms have migrated along the ureters. During their 
migration their presence has not been manifested by any symptoms. 
In the majority of cases even the symptoms of pyelitis disappear after 
a time, and the patient makes a good recovery; but in a certain pro- 
portion there is a systemic infection from the kidneys. There may be 
extensive suppuration of the kidneys and surrounding tissue, with fatal 
results, or, as the writer has seen in several cases, the symptoms of 
general systemic infection become so grave as for a long time to threaten 
the patient's life. In the worst cases of bladder infection the mucous 
lining sloughs, peritonitis develops, and the patient dies before the 
disease has time to infect the kidneys. 

The practitioner, bearing in mind the serious consequences of sep- 
tic cystitis after labor, should always be on the watch for it, and 
should adopt an energetic treatment immediately upon its detection. 
A thorough disinfection of the bladder will remove all present symp- 
toms, and prevent the occurrence of grave and possibly fatal after- 
complications. To accomplish this purpose the writer employs a 
saturated solution of boric acid. One injection of a quart of this 
solution through a two-way catheter is usually sufficient. Occasionally 
it is necessary to repeat it or to follow it by several injections of boric 
acid solution. A 1 : 5000 oxycyanide of mercury solution may be 
employed if the first boric acid injection fails to improve the local 
symptoms. 

After the irrigation of the bladder 4 ounces of a 25 per cent, argyrol, 
or a 5 per cent, emulsion of iodide of silver, a 1 per cent, solution of 
hegonon or a 5 per cent, solution of silvol is injected and allowed to 
remain till the next spontaneous urination. 

If infection of the kidneys ensues, a stimulating and supportive plan 
of treatment with salol, milk diet, and urotropin is indicated. The 
pelves of the kidneys should be washed out through the two-way 
ureteral catheter and then injected with one of the silver salts in weak 
solution. If extensive suppuration occurs in the kidneys, the pelves 
may be opened and drained by lumbar incisions, or if the suppuration is 
confined to one kidney, nephrectomy may be indicated. 

Perhaps the most uncommon point of septic infection after labor is 
the rectum. The writer has, however, seen one fatal case of this 
sort — from the use, no doubt, of a dirty syringe-nozzle in the hands of 
a careless nurse. Septic proctitis is treated by boracic acid solution 
irrigations and iodoform (5 grains) suppositories. 



PUERPERAL DISEASES. 893 

Next in frequency to the parturient tract and the urinary system as a 
region prone to infection after labor comes the breasts. Infection of the 
nipples, and a consequent mammary inflammation or suppuration, is 
one of the most troublesome minor complications that the obstetrician is 
called upon to treat. By careful preparation of the nipple during the 
last month of pregnancy, by extreme care to secure perfect cleanliness 
during the period of lactation, by emptying the breast and supporting 
it with a mammary binder, infection of the breast can almost surely be 
avoided. If it occurs, the first effort should be to limit its extent and 
degree, and to prevent, if possible, suppuration. The best means to 
accomplish this end are derivation of the blood from the mammary 
glands by an active purge, compression of the gland-substance, and 
support of the breasts by a suitable mammary binder. 

To these should be added, in the acute stage of inflammation, fomen- 
tations of very hot water, or the ice-bag, and, later, the applica- 
tion of cloths wrung out in alcohol and lead water, renewed every 
three hours, or a saturated solution of magnesium sulphate may be 
substituted. Unless the infection has been of a virulent nature and 
the amount of infective material large, this plan of treatment allays 
the inflammation and prevents suppuration. 

Bier's cups to create a local hyperemia are recommended by some, 
but the writer has found them painful to the patient and not as efficient 
as the treatment just described. 

The other infectious fevers of the puerperal state include the infec- 
tious diseases which might affect any adult female, and their treat- 
ment differs in no respect during the puerperium from that adopted 
under other circumstances unless there should be local complications. 



Non-infectious Diseases of the Puerperium. 

Anomalies of Involution. — Superinvolution, an exageration of that 
process by which the uterus is reduced to its normal size after labor, 
manifests itself, as a rule, only after the puerperal state is completed, 
and therefore its treatment need not be considered. 

Subinvolution, an arrested or retarded return of the uterus to its 
normal condition and dimensions after labor, is one of the commonest 
complications with which the obstetrician has to deal in the manage- 
ment of the puerperium. The cause of subinvolution is always a 
local one. General conditions, as acute fevers, have no influence what- 
ever upon the process of involution unless they are accompanied by 
some local complication. 

There are two causes of subinvolution. The involution may be pre- 
vented by anything which brings an excessive amount of blood to the 
uterine body, as, for instance, small fibroids within its walls or hyper- 
trophied deciduous membrane remaining adherent to its inner surface. 
Or subinvolution may be the result of meehanienl obstruction to the 



894 DISEASES. 

contraction of the uterine walls. An example is a retained placenta 
or a submucous fibroid or adhesions dragging the uterus out of place 
and preventing its contraction, or often an overdis tended bladder and 
rectum. 

In hypersemia of the uterus the cause of an excessive blood-supply 
must be sought and removed before the subinvolution can be remedied. 

If small fibroids can be detected, the administration of ergotin 1 
grain, hydrastinin \ grain, and stypticin 1 grain, in pill form, has been 
found most useful. Pituitrin (1 mil. of 20 per cent, solution) is 
undoubtedly one of the strongest stimulants to uterine contraction. 
If there is an hypertrophied endometrium retained within the uterus, 
a dull curette may be cautiously employed to remove it. In cases of 
heart disease in which the blood-current is sluggish and dammed 
back into the large veins of the trunk, digitalis is the most effective 
remedy to overcome the subinvolution. There may be an active hyper- 
semia associated with inflammatory action, either in the uterine wall 
or upon its peritoneal covering or in its adnexa ; in this case the inflam- 
mation must be overcome by disinfection, the use of purgatives, the 
local application of hot water, or possibly operative treatment, before 
involution can be secured. When there is mechanical obstruction 
to the return of the womb to its normal dimensions, the hindrance 
must, of course, be removed before one can expect a good result from 
treatment. Retained placenta must be removed. Submucous fibroids 
should be enucleated. 

Every labor results in some injury of the maternal structures. Usu- 
ally they are slight in degree, manifesting no symptoms and healing 
spontaneously. Occasionally the injury results in fistula communi- 
cating with the bladder or rectum, in deep granulating wounds in the 
vagina, or in ulcerated sores. 

In the case of fistula a cure can sometimes be effected without 
operative interference by touching up the edges of the fistulous tract 
with nitric acid, in order to excite an outpouring of granulation-tissue 
in the hope that it may plug the opening. In deep tears, which have 
not been primarily united, application of a solution of nitrate of silver 
will hasten the cure and prevent infection of the wounded surface. 
If ulceration occurs, the ulcerated spots are to be carefully watched 
and treated in the same manner. All the injuries of the birth-canal 
should be repaired by primary, intermediate, or secondary operation. 

Hemorrhages from the birth-canal after labor depend upon a num- 
ber of well-known causes, which must be sought out and corrected 
before the bleeding will cease. Most frequently the cause of a hemor- 
rhage will be found in retained placental fragments, which must be 
removed. Frequently displacements of the uterus will be found as a 
cause, and correction of the displacement will check the bleeding. 

In interstitial bleeding after labor, resulting in hsematoma, care 
must be taken to preserve the parts in as aseptic a condition as pos- 
sible, while an attempt is made to limit the bleeding by the application 



PUERPERAL DISEASES. 895 

of direct cold, preferably by means of a colpeurynter dilated with ice- 
water, which must be removed from time to time in order to allow 
the lochia to escape. After rupture or incision of these blood-tumors 
the cavity left behind must be carefully disinfected with tincture of 
iodine, and, if necessary to control further bleeding, well packed with 
iodoform gauze. 

Of all forms of bleeding, that which occurs directly after labor in 
consequence of inertia uteri, known as post-partum hemorrhage, is 
the most frequent, the most alarming and dangerous In its manifesta- 
tions and consequences. No one should attend a case of obstetrics 
without having in mind a clearly defined programme to be put in 
immediate execution when called upon to deal with this frequent and 
dangerous complication. There are two indications to be met: first, 
to control the hemorrhage, and, second, to treat the after-condition. 
The first indication is met by the following plan of treatment: 

External stimulation of the uterus by kneading and rubbing through 
abdominal walls, as is practised in Crede's method of expressing the 
placenta. 

If this fails carry the aseptic (gloved) hand into the uterus and 
remove any blood-clots, pieces of placenta or membrane that may be 
found there, and manipulate the parts so that the internal surface of 
the uterine walls is # irritated by the movements of the operator's fingers. 

The most certain and effective treatment is packing the uterine 
cavity with plain sterile or iodoform gauze. Too much time should 
not be wasted on other measures before resorting to the intra-uterine 
pack. 

The physician should give ergot, ergone, or ergot aseptic in full dose 
hypodermically with pituitrin added. 

Drugs, as the styptic salts of iron, and especially Monsel's solution, 
have been recommended from time to time as intra-uterine applica- 
tions in the case of post-partum hemorrhage, but they are dangerous, 
for the coagulation produced by them may extend far into the uterine 
vessels, and the clots can only be broken up by putrefaction, exposing 
the patient to the danger of septic poisoning. 

Excessive hemorrhage (post-partum) from lacerations along the 
genital canal can be controlled by well-placed sutures. 

Bearing in mind this plan of treatment, it is not likely that an 
intelligent and skilful practitioner will lose a case of postpartum 
hemorrhage. 

Treatment of the After-condition.— While the physician is engaged in 
controlling the hemorrhage the nurse should administer a hypodermic 
injection of caffeine sodium benzoate or of camphorated oil, if symp- 
toms of shock or collapse are manifested. After the bleeding has 
ceased it is well to administer salt solution by the bowel by Murphy's 
method (see Peritonitis), which maintains the patient's tempera- 
ture, relieves the shock, and by its irritation promotes contraction 
of the uterine muscle. The submammary or intravenous injection 
of normal salt solution is more efficient than the enteroclvsis, but 



896 DISEASES. 

more difficult for the ordinary physician to administer. In desperate 
cases the patient should receive adrenalin and strophanthin of stro- 
phanthone intranveously. This should be succeeded by small doses of 
hot, strong brandy and water, and a little warm milk if the stomach 
will retain it. As soon as reaction is well established a half-pint 
(240 mils) of hot beef-tea should be administered, and a hypodermic 
of | grain (0.008) of morphine given, in order to secure quiet and 
rest and to get the stimulant qualities which this drug undoubt- 
edly possesses. Occasionally measures must be adopted to retain 
enough blood within the large vessels and in the heart to prevent 
excessive cerebral anaemia or cardiac failure. This is best done by 
auto-transfusion: that is, by bandaging the extremities from below 
upward, in order to secure as large a quantity of blood as possible 
within the vessels of the trunk and brain. Intravenous injection of a 
0.9 per cent, solution of common salt is required when there are pro- 
found exhaustion and depression after hemorrhage. If it is impractic- 
able to throw this solution directly into the bloodvessels, an interstitial 
injection seems to answer the purpose equally well. The most con- 
venient place for such injections in females is under the breasts. (See 
Hypodermoclysis, Part III). Actual transfusion by the citrate of 
sodium method has given brilliant results in the most desperate cases. 
The milk secretion during the puerperal state presents abnormalities 
which call for treatment. One may have to deal with anomalies of 
quantity or quality. The most frequent anomaly of quantity in milk 
secretion is unfortunately one of deficiency. Insufficient milk-supply 
depends on a number of causes. Perhaps the most frequent is a lack 
of development of the glandular tissue, and in this form of insufficient 
milk secretion no treatment can be of avail. When the lack of milk 
is due to some intercurrent affection in the puerperal state the treat- 
ment must be directed toward this complication before the milk-supply 
can be re-established in normal quantity. It may be the consequence 
of hemorrhages or of diarrhoea, or the result of an acute febrile attack 
during lactation, or of inflammation within the gland itself. Serious 
organic disease may also be a cause, and insufficient nourishment 
must be held accountable in some cases. Profound emotions exert 
an extraordinary influence upon lactation in altering both the quantity 
and the quality of the milk. It has long been supposed that the return 
of menstruation has a disastrous influence upon milk secretion. This, 
however, has been definitely disproved by careful observations. The 
return of normal menstruation without complications has no apparent 
influence, as a rule, upon the quantity or quality of the woman's milk. 
In all the temporary diseases interfering with milk secretion described 
above, it should be borne in mind that on the disappearance of the 
abnormal general or local condition milk secretion can be successfully 
reestablished even though it be absent for days or weeks. Electricity 
has been much vaunted as a remedy for insufficient lactation. It may 
be applicable in cases of torpidity of the mammary gland or in those 



PUERPERAL DISEASES. 897 

cases where lactation has been suppressed on the birth of a first child, 
and where the mammary gland, therefore, does not respond readily to 
the stimulus of subsequent births. This remedy will, however, often 
prove ineffective and disappointing. 

The use of Bier's cups to produce local hyperemia is logical and has 
proved efficient. 

Pituitrin has been shown to be a galactogogue in animals and 
possibly in women. It may be given by the mouth or hypodermically, 
and it has seemed to the writer to be efficient. Placental extract is at 
present under trial for this purpose. 

Instances of excessive milk secretion are not infrequently met 
with. The milder and simpler forms can be managed by regulation 
of the diet and free purgation. Galactorrhcea, a constant flow of 
milk from the breasts, is one of the most stubborn forms of excessive 
milk secretion. Two measures can usually be relied on to give relief: 
firm compression of the mammary gland with the application of bella- 
donna ointment, and the administration internally of iodide of potas- 
sium. In some cases of this character milk secretion stops spon- 
taneously with the return of menstruation, and in a certain proportion 
of cases a treatment to secure a discharge of blood from the uterus 
has been successful in stopping the flow of milk. Success has been 
obtained with Simpson's plan of introducing a piece of caustic within 
the uterus in order to bring back the menstrual flow, but this local 
treatment has been superseded by the safer plan of applying the 
negative pole of a galvanic current (15 milliamperes) in utero. Warm 
douches have been used successfully. Electricity to the mammary 
glands has been recommended to secure the proper contraction of the 
sphincter muscles of the lactiferous ducts, but as this is a result, and 
not a cause, of the galactorrhcea, electricity proves ineffective. The 
long-continued administration of ergot has been warmly recommended. 
The remedy should be tried, for its use is rational. Chloral has been 
shown to be very effective in diminishing the quantity of milk. This 
drug, therefore, is worthy of trial. It has been declared that antipyrine, 
in 2|-grain (0.15) doses three times a day, will diminish milk secretion. 
The drug, however, has not been tested often enough to demonstrate its 
power. Quantitative anomalies in the milk secretion most often 
depend upon an ill-regulated diet. A fatty diet diminishes the quantity 
of milk; a vegetable diet diminishes the casein, and fat increases 
the sugar; a diet rich in meat, especially if reinforced with alcoholic 
stimulants, increases the fat and casein, but diminishes the sugar. 
If the mother's milk is evidently disagreeing with the nursing infant, 
a chemical analysis of it should be made, and on the result rules regu- 
lating the diet should be adopted. The most common mistake in 
practice is to overfeed a nursing woman, especially with a milk diet, 
with the idea which prevails extensively among the laity that the cows' 
milk poured into the stomach appears again in the mammary gland. 
It is usually sufficient for a nursing woman to observe the ordinary 
57 



898 DISEASES. 

diet which agrees with her under all circumstances, with the addition 
of a half -pint of milk midway between the morning and mid-day and 
mid-day and evening meals. Occasionally a wineglassful of malt 
at the mid-day and evening meals is a useful addition to the diet, 
and in anaemic patients the addition to the malt of 5 grains (0.3) of 
pyrophosphate of iron is an advantage. 

There is found in every pregnant woman some alteration in the 
constitution of the blood, which consists, roughly speaking, of a dimi- 
nution of the red blood-corpuscles and of the albumin and the iron 
in the blood, with an increase in the white blood-corpuscles and the 
serum. In some cases this change is much exaggerated, so that an 
intense degree of anaemia appears in the puerperal state which, in 
its severity, simulates pernicious anaemia or some fatal form of blood 
disease. The anaemia of puerperal women, however, even in severe 
cases, usually yields to treatment. After the continued use of Blaud's 
pills the writer has seen the blood-corpuscles rise from less than three 
to nearly four and a half millions, and the haemoglobin increase from 
40 to 75 per cent, in a few weeks. In some cases arsenic alone succeeds 
where iron fails completely. If a quick result is desired the best 
treatment is the hypodermic injection of citrate of iron and caco- 
dylate of sodium. 

Eclampsia. 

To treat eclampsia intelligently and successfully it is necessary to un- 
derstand its etiology as fully as modern knowledge permits. Although 
the subject needs more light from future investigations, enough is now 
known to justify the following statement: 

1. The cell-activity of mother and foetus produces toxins which are 
poisonous to the whole organism unless they are voided or made harm- 
less by the excretory organs. 1 

2. The organs in the childbearing woman are often inadequate to 
produce antidotes to or to eliminate these toxins. 

3. Consequently, poisons, of a nature not yet demonstrated, are 
stored up in the maternal blood until, by cumulative action, their 
presence is manifested in the eclamptic seizure and other symptoms. 

4. The convulsions are probably the result of an acute cerebral 
anaemia brought about by violent contraction of the arterioles. As a 
result of intense muscular action the circulation is interfered with, and 
blood is determined into non-muscular regions, as the brain, lungs, kid- 
neys, etc., to such a degree that the congestion of these parts becomes 
dangerous, leading to apoplexy in the brain, oedema in the lungs, and 
often a complete abrogation of renal function. 

The toxins exert an effect upon the lobules of the liver like phosphorus 
or chloroform, causing degeneration of the cells. The indications for 
treatment in convulsive seizures of this nature are plain: 

1 Harold C. Ernst, American System of Obstetrics, vol. ii, p. 431. 



PUERPERAL DISEASES. 899 

First, to eliminate the toxins from the blood as quickly and in as large 
quantities as possible. Second, to diminish nervous sensibility and 
lessen muscular power, in order to reduce the convulsions in vehemence, 
duration, and frequency. Third, if convulsions occur during labor, 
to save the infant without adding to the risk of the mother. Fourth, 
to guard the woman from injury during the attack 

The first indication is met by venesection, diaphoresis, and catharsis. 
By the first, one eliminates a certain quantity of poison along with the 
blood and relaxes the muscles. If there is sharp postpartum hemor- 
rhage, or if the patient is from any cause weak and anaemic, blood- 
letting is not called for. In the ordinary case, however, with full 
pulse, congested head, the veins standing out upon the neck and face, 
and a high blood-pressure, venesection is an undoubted advantage. 
While the median basilic of one or both arms is being opened some 
croton oil should be sent for, and 2 minims (0.1) mixed with sweet oil 
may be placed upon the tongue. As the stomach and intestines may 
add to the toxsemia by absorption of their contents, the stomach 
should be washed out with the stomach-pump and the colon should 
be irrigated. If the stomach pump is used the laxative can best 
be administered through it, 2 ounces of castor oil with 2 minims 
croton oil added can be directly introduced into the stomach. Direc- 
tions should at the same time be given to wring out four blankets in 
hot water; these are wrapped around the legs, trunk, and arms, and 
well covered over with one or more dry blankets. A steam bath in a 
portable cabinet, or immersion of the patient's body in a bath-tub full 
of hot water (99° F.), is more efficient if practicable. A submammary 
injection of a pint of normal salt solution is a valuable aid in producing 
free diaphoresis. The sweating thus induced is profuse. An ice-bag 
must be put to the head to prevent overcongestion of the brain. If 
the patient does not sweat well, salt solution should not be injected. 
The sweats and injection of fluid should alternate two hours apart, 
but the fluid after the first injection should be by the bowel, and 
instead of salt solution it is now an accepted practice to instil into the 
bowel, by the Murphy method, bicarbonate of sodium solution 5 j-Oij 
to combat the acidosis which is usually present in eclampsia. In 
this way, directly and indirectly through the skin and bowels, one 
eliminates the cause of eclamptic convulsions as quickly and thor- 
oughly as possible from the blood. The latter may be acted upon 
by i grain of elaterium rubbed up in butter, or by compound jalap 
powder and calomel, instead of the croton oil. If the patient can- 
not swallow, the stomach-pump may be used as already stated to 
introduce castor oil into the stomach. Pilocarpine seemed at 
one time an ideal remedy to secure diaphoresis in eclamptic cases, 
but it has fallen into well- deserved disrepute. It much increases the 
danger of pulmonary oedema, and is too profound a depressant. It is 
no longer employed by experienced obstetricians, except in postpartum 
eclampsia, when the hot baths do not result in a satisfactory sweat. 



900 DISEASES. 

The second indication is best met by morphine in full doses: Stro- 
ganoff who advocates the sedative treatment in eclampsia as most 
important, insists on absolute quiet. Avoidance of all physical and 
psychical initiation and the narcotization of the patient. He and his 
followers have secured a remarkably low mortality by this treatment. 

Anaesthetics are of little use. Chloroform employed for any length 
of time produces the same hepatic degeneration as the toxins of 
eclampsia, and ether damages the kidneys. 

If convulsions come on during labor, the child should be rapidly 
extracted as soon as the os is well dilated, but not before, because 
efforts to dilate the os cause shock, increase the convulsions, and distract 
the physician's attention from the woman's most threatening danger. 
Moreover, the os usually dilates with rapidity during eclampsia. 

In consequence of experiments showing the relationship between 
the parathyroids and tetany, parathyroid extract in one-grain doses is 
a logical addition to the treatment and has appeared to be effective. 

The high blood-pressure of eclampsia is recognized as one of its 
dangers; measures to reduce the systolic pressure should always be 
considered. The most effective are blood-letting, puncture of the 
membranes, sweating, veratrum viride (see Part II), and nitroglycerin. 
Lumbar puncture is receiving a trial, but it is too soon to judge of its 
effect. 

The only injury to be feared during eclamptic attacks is wounds 
of the tongue from the teeth. They can be prevented by inserting 
between the teeth a brush-handle wrapped in a handkerchief or by 
drawing a towel into the mouth like a bit. Well-meaning but ignorant 
bystanders sometimes throw themselves upon an eclamptic patient 
to restrain her convulsions by force. This should be forbidden. 

RETINITIS. 

Retinitis, or inflammation of the retina, is commonly the result of 
constitutional diseases, for example, Bright's disease, diabetes, syphilis 
etc., of altered states of the blood and bloodvessels, infections, toxins 
and traumatisms, or it may be due to the extension of a diseased process 
from an inflamed iris, ciliary body or choroid. The general remedies 
must be directed according to the cause, and the eyes must be protected 
from light, and all close work avoided. Very distinct retinal irritation 
may be caused by eye-strain, which is to be relieved by the prolonged 
use of atropine and dark glasses, and later suitable lenses for the 
correction of any existing error in refraction. 

RHEUMATISM (ACUTE ARTICULAR). 

No better example of the fact that therapeutics is in advance of 
pathology can be adduced than the disease known as acute rheu- 
matism. The therapeutist cannot tell how he cures the condition 
designated by this name, simply because the pathologist cannot tell 



RHEUMATISM. 901 

what the cause of the disease is. At the present time it would seem 
probable that the salicylates exercise a good effect by affecting a specific 
micro-organism or its educts. It must be remembered, however, that 
all cases of acute multiple arthritis are not articular rheumatism. In 
many cases they are due to the gonococcus, the pneumococcus, or other 
pathogenic germs, and in all such instances the salicylates are useless. 
(See Vaccine and Phylacogens.) 

The treatment of acute articular rheumatism is divided into that 
portion devoted to the cure of the disease-process, and that directed to 
the relief of the pain and of the other local manifestations of the disease. 

A solution of bicarbonate of sodium, 20 grains to the ounce (1.3-30.0), 
may be applied to the joints involved, by means of lint wet with this 
solution, with diminution of the sense of heat or burning, or ice-cold 
compresses may be tried. In other cases relief may be obtained by 
applying hot cloths saturated with the so-called Fuller's lotion — namely, 
carbonate of sodium 6 drachms (24.0), laudanum 10 ounces (300.0), 
glycerine 2 ounces (60.0), and water 9 ounces (270.0). Sometimes 
much benefit can be obtained by fixation of the joints by means of 
splints. 

A most valuable application to the inflamed joints of rheumatism, 
and the one the author has employed for many years to the exclusion of 
all others both during the acute stage and afterward when they remain 
swollen and enlarged, is : 

^— Ichthyolis gij (60.0). 

Adipis lanac hydrosi §ij (60.0). — M. 

S. — Smear thickly over the joint and apply on lint in addition. 

In other cases the acute stages of the inflammation may be combated 
with advantage, particularly when there is gastric disorder, by the 
local application of salicylic acid made into an ointment with an animal 
fat, not vaseline or glycerin, as it is not absorbed when so mixed. 
According to Bouget, this treatment is best suited to blondes and 
young persons, as. absorption is more rapid in this class of patients. 
The following salve may be prescribed: 

3— Acidi salicylici . 5j (4.0). 

Olei terebinthinae tt|xxx (2.0). 

Adipis lanae hydrosi §j (30.0). — M. 

High fever is to be controlled by the same measures as the high fever 
of any other disease — by cool sponging, or sponging with tepid water, 
and sometimes by the use of antipyretic drugs, the use of which is 
more justifiable in this case than in ordinary fevers in that they tend 
to relieve the pain. 

Immediately on seeing the patient the physician should resort to 
salicylic acid or its salts. It is worthy of note that good results gener- 
ally follow rapidly; that is, the salicylates give relief in from three to 
four days, or fail altogether. It is most important to remember that 
salicylic acid protects the cardiac valves and the entire endocardium 



902 DISEASES. 

from the ravages of the disease only by shortening the attack, and not 
by any direct influence; and in addition that this acid, by reason of the 
profuse sweats often produced by it and its tendency to cause cardiac 
depression, must be watched lest it act unfavorably on the general 
systemic state. 

The proper use of salicylic acid is often misunderstood, and it fails 
to produce good results sometimes because of this fact. Whenever 
acute articular rheumatism appears the salicylic acid should be pushed 
in the same way that we use quinine on the advent of a malarial 
paroxysm — namely, in full dose. 

It is useless to give salicylates in 5- or 10-grain (0.3-0.60) doses 
three times a day; they must be given in 20- to 30-grain (1.3-2.0) doses 
or more, morning, noon, and night, or oftener, or not at all. If the 
sweats are too severe or the stomach rebels, they may be stopped, but 
not decreased in amount unless for good reason. Further than this, 
if salicylic acid is used for three or four days in this way, and pro- 
duces evidences of cinchonism, yet fails to alter materially the course 
or severity of the trouble, it should be withdrawn, as it will rarely if 
ever do any good after this time because the disease is due to an infec- 
tion of the joints by some micro-organisms upon which the salicylates 
have no influence and vaccino-therapy may be essential. (See Vaccine 
Therapy and article on Salicylic Acid, Aspirin, and Novaspirin.) 

Lees also asserts that the salicylates often fail in acute rheumatism 
because the dose is not large enough. He advocates as much as 300 
grains a day to a child, and insists that large doses of bicarbonate of 
sodium are necessary to prevent evil effects from these doses. The 
chief of these is "air hunger" or dyspnoea. The author would be 
afraid to use such large amounts, but this view of Lees emphasizes 
the fact that the doses used are often too small. 

In the author's experience the salicylate of strontium is a very useful 
substitute for the acid, as it is less apt to irritate the stomach. 

Clinical experience seems to show that if sodium bicarbonate is 
given in full doses with the salicylates, better results are obtained 
than if the salicylate is used alone. The dose of the bicarbonate of 
sodium should be about 20 to 30 grains (1.3-2) three or four times 
a day. It is also thought that this mixture protects the heart, whereas 
the salicylate when given alone fails to do so. 

Acetanilide does good by benumbing the sensibility of the patient to 
the excruciating pain consequent upon movement, and so putting aside 
the nervous wear and tear of sleeplessness and suffering. Further 
than this, it would seem probable that acetanilide possesses a direct 
antirheumatic influence. The author has found that acetanilide in such 
cases will often relieve the pain, and so permit a refreshing sleep, in 
doses of from 4 to 8 grains (0.25-0.50) three times a day, and that these 
amounts do not cause the excessive sweating which the necessarily 
large doses of salicylate sometimes produce — sweats which leave the 
patient oftentimes almost dyspnceic from very weakness. Whether this 



RHEUMATISM. 903 

temporary relief produces such changes in the system as to permit of 
a better battle against the disease, or whether it actually counteracts 
the rheumatic poison, we do not know. 

The following prescription, which is of additional value because 
the caffeine supports the heart and increases urinary secretion, may 
be employed: 

1$ — Acetanilidi gr. xl (2.6). 

Caffeinse . gr. xx (1.3). 

Camphorse monobromatis gr. xx (1.3). — M. 

Fiat in capsulas vel pilula? No. xx. 

S. — One every three hours or three times a day. 

Phenacetin is often very useful when used in rheumatism for the 
relief of pain, particularly if combined with phenyl salicylate (Salol). 

In some cases there can be no doubt that rheumatism phylacogen is 
specific in its effects. (See Phylacogens, Part II.) 

Passing from what may be appropriately called the coal-tar treatment 
of rheumatism, because many of the drugs so far named for internal 
use have such a source, we come to a list of remedies heretofore largely 
used in rheumatism in place of the newer compounds, but which are 
not so commonly employed to-day. 

These remedies act, as a rule, in the subacute forms of rheumatism 
or in the cases where the first group fail because the disease is obsti- 
nate. Of these the chief is the iodide of potassium, followed by the 
acetate, bicarbonate, and citrate of potassium. If the iodide is used, 
the following prescription is of service: 

1^— Potassii iodidi §j (30.0). 

Syrupi sarsaparillae compositi . . . . f §vj (180.0). — M. 
S. — Dessertspoonful (8.0) three times a day, after meals. 

In other cases it is best, because of the disagreeable taste of the 
iodide, to give it in sugar-coated pill or in tablet form, but care should 
be taken that milk or water is taken at the same time to prevent gastric 
irritation. 

Or, if preferred, 20 to 30 grains (1.3-2.0) of the bicarbonate of 
potassium may be taken every four or five hours in water flavored with 
cinnamon for the sake of the taste, or the citrate of potassium, which 
is more agreeable, may be taken in equal amount. If the case is very 
obstinate, sometimes a little colchicum added to the prescription given 
above may be useful, as follows: 

R —Potassii iodidi ■ . m 3j vel §ij (30.0-60.0). 

Vini colchici seminis . . . . . foss vel fgj (15.0-30.0). 

Syrupi sarsaparillae compositi . q. s. ad f § vj velf §xij (180.0-360.0). — M. 
S. — Dessertspoonful (8.0) three times a day, after meals. 

The other drugs used in acute rheumatism are numerous, but only 
a few of them deserve attention here. There is abundant evidence 
on record that full doses (10 to 30 minims [0.60-2.0]) of the fluid- 
extract of cimicifuga if given every five hours will decrease the redness 
and pain of the joints and shorten the attack in some cases. 



904 DISEASES. 

Many cases of acute rheumatism will do well if a strong mixture 
of lemon- or lime-juice and water be taken daily in large quantities. 

The local remedies in the later stages of acute rheumatism are 
chiefly counterirritants and sedatives. Thus, small or large blisters 
applied around a stiffened joint after the general systemic excitement 
has passed may be of great value in restoring the suppleness of the 
joint and in aiding in the absorption of the effusion. The remaining 
local treatment consists in thoroughly painting the stiffened joints 
with tincture of iodine if blisters are not used, or in the application of 
veratrine ointment or iodine ointment around the joint. (See Vera- 
trina.) Sometimes the application of ichthyol and lanolin in equal 
parts, also rubbing this ointment into the tissues thoroughly, will aid 
in the absorption of inflammatory exudates. 

In this connection we must not forget the great value of morphine 
in endocarditis, myocarditis, and pericarditis; for not only does this 
drug give relief from the pain, but it also diminishes the patient's 
anxiety, quiets his restlessness, and slows the pulse by this means and 
by direct action upon the circulatory system. This question of slowing 
the heart does not receive sufficient attention. When we consider 
that a difference of ten beats a minute amounts to 600 beats per 
hour, and to nearly 15,000 beats a day, we can see how comparatively 
slight variations in pulse rate may mean very great variations in the 
amount of work done by the heart in twenty-four hours. For the pre- 
vention of relief of endocarditis the application of a number of small 
blisters over the prsecordium seems to be a very valuable measure; 
or, in their place, 8 to 12 leeches may be placed over the heart and 
followed by the application of an ice-bag. (See article on Peri- 
carditis.) 

No drugs can serve to protect the heart so well as complete physical 
rest. Not only is this necessary during the attack, but for several 
weeks afterward; and if the patient gets up too soon, a latent, unsus- 
pected valvulitis may gradually develop into a fatal lesion. The 
lame valve must be given time to recover before it is given more work 
to do. This is perhaps the most important therapeutic fact in regard 
to the therapy of this disease. 

RHEUMATISM (CHRONIC ARTICULAR). 

Chronic rheumatism is one of the most obstinate diseases with 
which we have to deal. In some cases the acute form just consid- 
ered merges slowly into the chronic form, or, in other instances, the 
disease develops gradually, increasing, it may be, by exacerbations 
or by gradual progression. In a large proportion of cases it is usually 
a low grade septic arthritis, in which the joints suffer from a single or 
multiple infection. In other cases the cause is a rheumatic or gouty 
diathesis. (See Vaccine Therapy and Phylacogens.) 

The treatment of chronic rheumatism is somewhat different from that 
of the more acute form, and approaches that of gout in some of its 



RHEUMATISM. 905 

therapeutic indications. In other words, the salicylates are not so use- 
ful in these cases as are the iodides and colchicum, so that in the majority 
of instances the prescription of iodide, sarsaparilla, and colchicum given 
in the article on Acute Rheumatism is indicated. When anaemia or weak- 
ness is present, cod-liver oil is often of great service, and it is worthy of 
note that this useful nutritive remedy was first brought into therapeu* 
tics by the fishwives of Holland, w T ho found it useful in the attacks of 
rheumatism to which their husbands were subjected through exposure. 

When the oil is thoroughly rubbed into chronically inflamed joints 
it is almost as useful as when taken internally. 

The same forms of severe counterirritation are not so useful in chronic 
rheumatism as in the subacute form, but a very valuable therapeutic 
measure in these cases is the use of the Russian or Turkish bath or an 
improvised hot bath by means of a lamp and a blanket. (See Heat and 
Cold.) Liniments are always called for, for two reasons: first, they 
relieve pain and do good to the parts, if not from their medicinal prop- 
erties at least by the Tabbing which accompanies their application: 
second, because they give the patient something to do or to have done, 
and therefore impress him with the object-lesson that his attendants 
are attentive and alive to his suffering and need of sympathy and care. 

iVmong the lower classes the belief in liniments is widespread, and 
their use will often instil into the minds of the friends a far greater 
confidence than the most rational of treatments with the liniment left 
out of the list of remedial measures. The following liniments will be 
found useful under these circumstances. 

1$ — Tincturae aconiti f 3vj (24.0). 

Tincturae opii f §j (30.0). 

Olei terebmthinae f 5 j vel foij (30.0-60.0). - 

Linimenti saponis . . . q. s. ad oviij (240.0). — M. 
S. — Poison. Use as a liniment three times a dav. 

Or, 

1$ — Aquae ammonia? for tioris .... f 3iv (16.0). 

Olei cajuputi foj (4.0). 

Tincturae belladonna foliorum . . foj vel foij (30.0-60.0). 

Linimenti camphorae . . q. s. ad f5viij (240.0). — M. 
■S. — Poison. Use as a liniment. 
Or, 

1^— Tincturae aconiti fSj (30.0). 

Tincturae opii, 

Aquae ammoniae fortioris . . . . aa f 5iv (16.0). 

Linimenti chloroform! f 5vj (180.0). — M. 

S. — Poison. Use as a liniment to chronically inflamed muscles or joints. 

In other instances the greatest relief is obtained by employing the 
following ointment : 

1^ — Veratrina? gr. xxx (2.0). 

Hvdrargvri iodidi flavi 5j (4.0). 

Petrolati" oij (60.0).— M. 

S. — Use as an ointment over the joints. 

This ointment ought not to be widely distributed, and the pulse and 
respiration should be watched, as the veratrine may be absorbed and 
depression of a severe character set in. 



906 DISEASES. 

For the reduction of enlargements of the joints due to the disease, 
and accompanied in some cases by pain, the following ointment is 
serviceable : 

I$— Unguenti iodi 5j (30.0). 

Adipis 3iwel §j (15.0-30.0), 

S. — Apply locally. 

Or, still better, 

g— Ichthyplis 3 iv to §j (15.0-30.0). 

Adipis §j (30.0).— M. 

S. — Rub into the joints thoroughly. 

In many cases ichthyol is certainly the most efficient remedy for the 
enlarged and painful joints. (See Feet.) 

The employment of red flannel over the inflamed joints is no better 
than the use of white flannel, and it is never beneficially "medicated/' 
as claimed in the stores. The only advantage of red flannel is that, as 
it is dyed, the wool is often better for not being thoroughly bleached, 
and is in larger amount. The disadvantages of red flannel are that if 
the patient sweats the dye stains the clothing, and the possibility of 
its producing irritation of the skin or even systemic effects of an evil 
character. 

It is important to remember that many cases of " rheumatism" are, 
in reality, due to muscle strains produced by deformity, as disease or 
weakness of the spine or flat-foot. 

RICKETS. 

Rickets may be defined as a state of the body of an infant or child in 
which there is a deficiency of the normal salts of the bones and tissues, 
with corresponding enlargement of the organic portion of the bone, or, 
in other words, the cartilaginous parts. Generally the term is applied 
solely to designate bony troubles, but every practising physician sees 
cases where the manifestations of rickets are emphasized in gastro- 
intestinal disorders rather than in bony deformities. The chiel cause 
of rickets in children, aside from the presence of any exhausting dis- 
ease, is inanition; that is, malnutrition of a specialized form, or, in 
other words, bone-salts starvation. This may occur after or before 
birth, and it is quite common to see children, born of mothers ill-fed 
or whose assimilation of salts is defective, with soft bones or a distinct 
tendency to rickety development. In other cases the condition is chiefly 
one of failure of assimilation rather than of starvation of bone salts. 

The treatment of rickets is therefore largely dietetic and devoted 
to the improvement of the food and digestion. In the presence of 
this disease no part of the body fails in force more than the diges- 
tive apparatus, probably because the character of the blood is altered, 
and partly because the stomach cannot secrete properly-formed juices 
from imperfectly nourished glands. 

The medicines to be used in rickets are general tonics, digestives, 



RICKETS. 907 

and stimulants, and bone tonics, such as salts of lime and phosphorus. 
The general tonics are quinine, cod-liver oil, nux vomica, and iron, 
while the digestive tonics are the simple bitters, physostigma, and 
mineral acids. 

Tonic treatment is best carried out in young children by the ad- 
ministration of quinine in the form of euquinine or by the use of 
strychnine in the dose of ?h to ttjo grain (0.0003-0.0006) in sugar- 
coated pink granules. Arsenite of copper in the dose of njo grain 
(0.0006) in tablet triturate three times a day is also useful. 

A very useful preparation is the following: 

1$ — Olei morrhuse f5vj (24.0). 

Syrupi calcii lactophosphatis, 

Liquoris calcis aa f^iij (90.0). — M. 

S. — \ to 1 teaspoonful (2.0-4.0) two or three times a day. Shake thoroughly. 

Nux vomica is so bitter as to be difficult of administration to young 
children, and when given only \ to \ minim (0.008-0.015) of the 
tincture should be used, three times a day. 

Where a distinct scrofulous tendency exists and anaemia is present, 
small doses of the syrup of the iodide of iron are of service, and 
J to 1 minim (0.03-0.06) may be given three or four times a day to a 
child of six months or a year, thus : 

1$ — Syrupi ferri iodidi gtt. xij vel xxiv (0.8-1.5). 

Aquae destillatse . . . . q. s. ad f giij (90.0).— M. 
S. — Teaspoonful (4.0) every four or five hours during the day, 

Or, 

1$ — Syrupi fern iodidi gtt. xij vel xxiv (0.8-1.5). 

Syrupi q. s. ad f oiij (90.0). — M. 

S. — Teaspoonful (4.0) three times a day, after meals. 

Here, again, arsenite of copper is a particularly valuable remedy. 

The salts of lime and sodium are of direct benefit to the bones, 
forming by their presence in health a large proportion of the osseous 
system, and therefore they may be considered as foods rather than 
drugs. Very often their administration to nursing mothers or preg- 
nant women saves the maternal teeth from caries and preserves the 
general health of the mother and child. The following prescription 
may be used : 

1^ — Syrupi calcii lactophosphatis . . . . fgiv (120.0). 
S. — \ to 1 teaspoonful (2.0-4.0) three times a day, after meals. 

The reasons for the use of phosphorus are clear, from what has 
been said of that drug when speaking of it elsewmere in this book, as 
it acts as a direct and powerful stimulant of bone-growth. 

Phosphorus is best given to children in the form of very small sugar, 
coated pills (^iro grain [0.0003]), such as are put up in the form known 
as "pink granules." 

The ventilation of the rooms where a child prone to rickets is kept 
should be excellent, not too hot or cold and free from draughts. A 



908 DISEASES. 

cool sponge-bath is useful at night if the patient is strong enough, or 
a good rubbing with salt and whisky, 1 drachm (4.0) of salt to a pint 
(480 mils.) of whisky, is of still greater service. 

Special attention should be paid to the development of the muscles 
by massage and passive movements, as these parts are always weak. 
Walking must not be allowed too early, as it may cause bony deformi- 
ties. 

RINGWORM. 

Many methods of treating this affection are employed and are more 
or less efficacious. Jackson recommends as the best the rubbing into 
the part of 1 drachm (4.0) of iodine crystals in 1 ounce (30.0) of real 
goose-grease. This grease has greater penetrating power than ordi- 
nary fats and usually is effective by the end of three weeks, the ointment 
being applied night and morning until some redness of the skin appears, 
when it is used once a day. Depilation is not necessary, for the hair 
soon falls out, but is supplanted by a new growth. This application 
may burn slightly, but is not really painful. 

SCARLET FEVER. 

This disease, the most fatal of all the exanthematous diseases of 
childhood, requires the greatest care in its treatment, but this does 
not mean the free use of drugs. We have no specific remedy and 
can only treat conditions which when they arise threaten danger. 
Complications often arise requiring skill on the part of the attendant, 
and it is upon his success in treating these outbreaks, as well as in the 
general direction of the case, that the life of the patient may depend. 

A milk diet alone or fortified by the use of carbohydrate gruels, 
not broths, partly predigested by takadiastase should be rigidly 
followed. 

The convulsions which rarely usher in an attack are to be treated 
by the use of the warm pack or hot bath (Part III), and if need be, 
5-grain (0.3) doses of chloral and 10 to 20 grains (0.60-1.3) of bromide 
of sodium given by the rectum for a child of five to eight years. 
The convulsions of the advanced stages are often ursemic, and must 
be treated accordingly. (See Ursemia.) 

From the very beginning of an attack to its end the child should 
always be supplied with plenty of pure water, and, if possible, this 
water should be obtained from a spring containing a low percentage 
of solids, as Poland water, which is widely sold throughout the United 
States. If this is impossible, then Celestins Vichy water may be 
employed unless dropsy is present. The object of this treatment is to 
flush out the kidneys, and to so dilute the toxic substances generated in 
the body, by the fever and the germs of the disease, that they lose, to 
a great extent at least, their poisonous and irritating powers. If the 



SCARLET FEVER. 909 

child is so young that it takes food from a nursing bottle, Poland watei 
may be placed in the bottle. 

In other cases a prescription containing sweet spirit of nitre and 
citrate of potassium proves useful, as follows: 

1$ — Spiritus setheris r.itrosi fgj (30.0). 

Potassii citratis 5ij (8.0). 

Aquae destillatse q. s. ad f Svj (180.0). — M. 

S. — Teaspoonful (4.0) every two hours if the urine is highly colored. 

Scanty urinary flow due to vomiting and deprivation of fluid should 
be treated by the use of the rectal drip. (See Peritonitis.) The use 
of daily hot packs is also useful to relieve the kidneys of congestion 
and quiet nervous irritability. Occasionally dry cups over the kidneys 
do good. 

. The further treatment of the disease rests upon the symptoms alone. 
We cannot cure the patient by the use of remedies, but we can do 
much toward making the pathway to health smooth and free from 
pitfalls and obstructions. 

Probably the most common complications calling for treatment when 
the kidneys have been treated in the way just spoken of, are high temper- 
ature or fever, and sore throat or angina. The fever is to be controlled in 
these cases in precisely the same way that it is in all other conditions in 
which it is present. It is best to attempt to keep it below 102° F., by tepid 
sponging, which also allays the itching of the skin, or, if the temperature 
continues to rise, by the use of colder water. Generally the popular fear 
that the application of cold to the surface will drive the eruption "in- 
ward" is so strong as to make the cold sponging objectionable to the 
friends; but if the temperature reaches 105° F., the physician must assert 
the fallacy of this belief and insist on its use. (See Cold, Part III.) When 
the patient is overcome by toxaemia, the skin marbled and mottled, and 
the brain stuporous, he should be placed in a bath at 100° F., and water 
at 60° or 70° F. poured on his head and shoulders with some force or the 
wet pack may be used. In very young children the same effect may be 
obtained by dipping the patient alternately in hot and cool water. The 
object is to cause reaction and equalize the circulation. If suppression 
of the rash occurs, the wet pack must be used. (See Heat, Part III.) 
Where the head seems to be particularly hot and the fever is high 
an ice-bag or a head-coil of rubber tubing is to be employed, and 
through the latter water may be circulated at whatever temperature 
is thought best.. (See Cold, Part III.) 

The treatment of the sore throat of scarlet fever is an important 
part of the care of the child in many cases. Small pellets of ice may 
be held in the mouth and an ice-bag applied to the outside of the 
throat. This is done by finely breaking some ice and placing it in 
a thin India-rubber bag about the neck, the surface of the bag being 
covered by a cloth to prevent too rapid melting of the ice and the wet- 
ting of the clothes by the condensation of moisture on the surface of the 



910 DISEASES. 

bag. This treatment may be used during the entire attack if needed, 
and the contents of the bag renewed as often as the water becomes at 
all warm from the heat of the body. By this means the redness of the 
fauces and the swelling of the glands of the neck are relieved. Chlorate 
of potassium may be used in a spray or on a swab, but never internally 
owing to its irritant effects upon the kidneys and stomach and its 
general influence on the blood. When a false membrane forms, anti- 
diphtheritic serum is to be given until a bacteriological examination 
shows that it is not due to the Klebs-Loeffler bacillus. This mem- 
brane should be locally treated by applying peroxide of hydrogen. 

In cases where the eruption suddenly fades or is never well developed 
it is of the greatest importance that it be made active. Under these 
circumstances the child may be placed in the warm wet pack, and, if 
the head is very hot, cold applied to the vertex and throat while the 
body is enveloped in the blanket. (See Heat.) This often brings out 
in an hour or two a bright scarlet rash, and the child falls asleep and 
wakes up free from delirium and high fever. 

The itching and burning of the skin in many cases of scarlet fever 
are annoying symptoms, and they may become really dangerous. Fever 
of high degree can be brought on solely through nervous irritation, 
thus explaining a fact long well known to clinicians — namely, that 
the relief of this dermal irritation in scarlet fever may be followed 
by a fall of temperature. To relieve this symptom it will often be 
found advisable to cover the entire skin with a thin layer of benzoated 
lard. Oftentimes a warm pack will relieve this symptom. In other 
cases almond oil should be used. 

If nephritis comes on and in a severe form, the greatest care is 
necessary, and the object of the physician must be to make the skin, 
disabled as it is, carry out sufficiently an active eliminative function to 
relieve the kidneys of strain, to remove dropsy. It is well to aid in the 
removal of effete matter by producing catharsis. Sweating may also 
be produced by the employment of heat obtained by the use of the hot 
pack or the mustard pack. (See Heat.) The thermometer must be 
placed in the mouth to foretell any danger from heat-stroke if the 
sweat should fail to appear. 

The after-treatment of scarlet fever during convalescence consists 
in the use of Basham's mixture or the tincture of the chloride of iron, 
and in the employment of simple bitters, strychnine, or quinine. 
Fresh air, sea air, or mountain air is useful, while cold or exposure to 
cold air or draughts is to be carefully guarded against. 

The view has been that the desquamated skin is the active factor in 
distributing the infection. If this be true it can be controlled by the 
use of oil inunctions and quarantine. The nasopharyngeal discharges 
are the chief agents in spreading infection, and these passages should be 
sprayed daily with normal salt solution and then dropping a 10 per 
cent, solution of argyrol into the nostrils preceded by a few drops of 
liquid albolene. 



SCROFULOSIS. 911 

SCIATICA. 

Sciatica is an exceedingly obstinate affection, in many cases resisting 
the best treatment for weeks. It seems to be due to rheumatic tendency 
in the majority of instances. In other instances it is due to injury or 
jarring of the nerve, as by heavy persons stepping off from a high 
step to the hard ground. Thus the most obstinate case ever seen by 
the writer was one in which a man weighing about two hundred and 
fifty pounds acted as "coupler" on a switching engine, and, though 
wonderfully agile for his weight, provoked the disease in the leg on 
which he always first struck the ground when jumping from the plat- 
form of the moving locomotive. 

The treatment for all cases is both internal and external. The 
internal treatment may be the same at that already described under 
Acute or Chronic Rheumatism, or in other instances consists in the 
use of large doses of bitartrate or citrate of potassium, 40 grains (2.6) 
three times a day, in plenty of water to aid in the maintenance of free 
kidney action. At the same time the amount of coffee and tea should 
be cut down as much as possible, and lemonade, with little sugar, 
be taken freely during the day. If the pain is excessive, morphine 
should be given, or aspirin, antipyrine, or acetanilide may be used. 
In some instances methylene blue in 5-grain (0.3) doses twice or 
thrice a day has seemed to relieve pain. (See Methylene Blue.) 

The local treatment of sciatica is quite various. The daily use 
of an ether or rhigolene spray over the part is effective, or kataphoresis 
may be resorted to. 

In acute cases, from three to five large wet or dry cups, preferably 
the wet, may be placed along the course of the sciatic nerve with great 
advantage. In many cases absolute rest of the limb, obtained by plac- 
ing it in splints, has to be adhered to before cure is possible. In other 
instances the nerve should be exposed and any adhesions broken up. 
Hot-water bags should be placed continually about the exit of the 
sciatic nerve from the pelvis. 

The liniments recommended in chronic rheumatism may be tried, 
and cod- liver oil is of service in some obstinate cases. 



SCLERITIS. 

(See Episcleritis, Page 768.) 

SCROFULOSIS. 

It is now universally recognized that scrofulosis is really a form of 
tuberculosis, yet, as its manifestations are often quite distinct, it is 
separately considered. 

Scrofulosis is to be treated by hygienic measures rather than drugs— 



912 DISEASES. 

fresh air, residence by the seaside, proper out- door exercise, massage, 
and dietetics, all of which take precedence of medicines. 

If these necessary adjuncts to a cure are obtainable, the prognosis 
is fair, to say the least, and the following drugs may be used, all of 
them being devoted to the improvement of the general health, and 
not to any direct influence over the scrofulous tendency in itself. Jt 
is hardly necessary to state that ^cod-liver oil is perhaps the best remedy 
of all. The oil should be given in emulsion, being first pancreatized 
and so prepared as to be somewhat palatable by the addition of flavor- 
ing substances if the child is old enough to appreciate such flavors. 
In young children, while distaste of the oil is often shown at first, 
a liking for it rapidly develops, so that the writer has seen children 
cry for it when the oil was discontinued. In these cases it is nearly 
always best to combine the lactophosphates or the hypophosphites 
with the oil. When anaemia is present, syrup of the iodide of iron 
is useful in from 1- to 10-minim (0.05-0.60) doses, according to the age 
of the child, as follows: 

I}— Syrupi ferri iodidi f 3ss vel f 3ij (2.0-8.0). 

Aquae destillatae . . . . q. s. ad f ohj (90.0). — M. 
S. — Teaspoonful (4.0) in water three times a day, after meals, to a child of 
one year. 

In place of iodide of iron, y^- grain (0.0006) of arsenic trioxide or 
Tiro grain (0.0006) of corrosive sublimate may be given to a child of 
three or four years, in the form of tablet triturates, or the following 
prescriptions may be used : 

1$ — Liquoris potassii arsenitis ttixvj (1.0). 

Aqua? destillatae foij (60.0).— M. 

S. — Teaspoonful (4.0) three times a day, after food for a child of five years. 

Or, 

1$ — Hydrargvri chloridi corrosivi . . gr. T V vel gr. ^ (0.006-0.012) 

Aquae destillatae foij (60.0).— M. 

S. — Teaspoonful (4.0) every five hours, after food. 

The use of iodides is generally contraindicated in those cases in 
which softening and breaking down of the glands are going on rapidly. 
In their place calx sulphurata may be employed, by placing 1 grain 
(0.06) of it in half a tumblerful of water and giving a teaspoonful 
hourly. The mixture should be freshly made every day, to prevent 
its becoming oxidized. 

When enlargement of the cervical glands takes place, iodine oint- 
ment, diluted, one-half of lard, should be well rubbed into the part 
twice daily, but it should be stopped at once if signs of softening or 
fluctuation appear or if the skin becomes reddened. In cases in 
which these enlargements are persistent, ichthyol ointment is to be 
rubbed in, using the following formula : 

T|— Ichthyolis .' . . . 5ij vel giij (8.0-12.0). 

Adipis 3j (30.0).— M, 

S. — Apply locally. 



SHOCK. 913 

If this is not followed by cure, the glands should be excised and the 
cavity packed with iodoform, as in the majority of cases these enlarge 
ments will be found to be distinctly tuberculous. (See Adenitis.) 

SCURVY. 

The cure of this state is so completely dependent upon the use of 
proper foods that almost no drugs are to be employed in the treat- 
ment of scurvy. 

The only remedies particularly indicated are orange- or lemon-juice 
or lime-juice or citric acid, the latter being far less valuable in all cases 
than the juice of the fresh fruit. Arsenic and iron are of service in 
most cases, and rest and quiet are to be insisted upon. 

By far the more common form of scurvy is seen in bottle-fed babies. 
The child may or may not have rhachitic manifestations. Generally 
it loses animation, becomes listless and peevish, evidently suffers pain 
in its body and limbs when it is lifted from the bed, and looks feeble 
and wan. The gums become spongy and swollen, and have an ecchy- 
motic appearance, and light blows produce bruises out of proportion 
to the severity of the injury. The treatment of infantile scurvy is a 
complete rearrangement of the child's diet-list, and varying its food. 
No one baby food should be used to the exclusion of another, and 
sterilized milk is to be supplanted, if possible, by fresh new milk. It 
is important to remember that a large proportion of these cases occur 
in the children of the rich, who have subsisted largely on prepared 
"Infant Foods." Beef -juice squeezed from a half-cooked steak is 
useful. 

SHOCK. 

The term shock is applied to a state in which the patient is in collapse 
as to his circulation and nervous energy. It is to be distinctly separated 
from syncope in which unconsciousness is present. The patient is often 
seemingly benumbed as to his mentality and may be profoundly 
apathetic, although, if spoken to, it is found that his intelligence is 
preserved even if he be so feeble that he does not speak in reply. It is 
unfortunate that very different states are described under this term and 
it is practically certain that the symptoms, although they may be 
similar in different persons, are nevertheless due to different causes and 
often to varying quantities of each cause. In other words, the cause of 
the condition is complex, not simple. All attempts to prove that shock 
is produced as the result of a single factor have failed. It is not possible 
in this space to deal with all the different theories as to cause but only 
with the dominant conditions present and what can be done for their 
relief. These dominant conditions are a marked fall in blood-pressure 
and a tendency to arrest of heat production and to an increase of heat 
dissipation. The fall of blood-pressure is to be combated by the use of 
58 



914 DISEASES. 

atropine given in full dose intramuscularly, since atropine tends to 
restore circulatory equilibrium by contracting the bloodvessels in and 
splanchnic area and dilating the peripheral vessels. The use of normal 
saline intravenously is of little value because the vessels dilate as fast 
as the fluid flows in and unless the fluid is hypertonic it may transude 
into the tissues. (See Intravenous Injections, Part III.) To prevent 
this not only is a hypertonic solution useful, say one of 1.0 instead of 
0.7, but its transudating properties may be arrested by the addition 
of sterile gum acacia. (See Intravenous Injections.) The patient 
should not be put flat but rather be placed in the Fowler position and 
should not be oppressed by being buried in soft pillows. Strychnine 
and particularly caffeine should be given intramuscularly in some cases 
in full dose. These drugs if used before exposure to the cause of shock 
may make the body unduly susceptible to it, but after the insult the 
caffeine in doses, of 3 to 6 grains rouses the nervous activities of the 
patient and calls in his reserve energies. The use of alkaline injections 
to combat so-called acidosis, while advocated by some observers, has 
not proved efficient and it has not been proved that acidosis is the cause 
of the symptoms or that the acidosis said to be present is sufficiently 
severe to produce them. Porter has urged the use of C0 2 inhalations 
on the basis that by increasing the amount of that gas in the blood 
the dominant vasomotor centre is stimulated to greater effort to raise 
pressure, and there are good physiological reasons, as well as clinical 
results, to support this view. The greater amplitude of thoracic move- 
ment under such inhalations also tends to pump the blood from the 
great venous trunks into the heart. We are too prone to forget the 
importance of respiratory movement as a circulatory factor. The 
greatest care should be taken that the patient is moved about as little 
as possible, that he have absolute quiet, and above all things that he be 
not exposed to cold. External heat should be applied to the extremities, 
but not so as to oppress him as it often does if his chest is packed about 
with hot-water bags. Hot normal saline may be given by means of the 
Murphy drip. (See Peritonitis.) If the heart flags some preparation 
of digitalis suitable for hypodermic use should be given in full dose 
intramuscularly, but the rapid or feeble pulse is more the result of low 
blood-pressure than of actual cardiac weakness. (For the use of 
adrenalin and pituitrin in vascular collapse, see Suprarenal Gland and 
Pituitary in Part II.) 

SMALLPOX. 

The treatment of smallpox is not specific, simply because it is one 
of those diseases which run a given course and which cannot be aborted. 
We can only treat the various symptoms which present themselves, 
and by the modification of these manifestations prevent complications 
and sequelae to some extent. The fever is to be treated as is any fever 
of this class. Often it can be allayed by a mixture containing tincture 



STINGS AND BITES. 915 

of aconite, spirit of nitre, and spirit of Mindererus (liquor ammonii 
acetatis), while the headache or backache may be controlled by small 
doses of antipyrine or acetanilide. Mustard plasters are not to be used 
for the backache, as the dermal irritation will increase the eruption. 
Insomnia and restlessness, if excessive, are to be quieted by the bro- 
mides or chloral, care being taken that the doses of the latter are 
not large enough to depress the heart. It must be remembered that 
the time of onset of the secondary fever, the eighth day, is one of grave 
import to the patient. More patients die from this secondary septic 
infection than from the disease itself. Before its arrival the treatment 
of the case must be so managed that strength is saved for this strain, 
and tincture of the chloride of iron, in 5- to 10- (0.3-0.60) or even 20- 
minim (1.3) doses, may be resorted to to give strength to the patient 
and to help control the pysemic fever. The pulse should be watched, 
and if it flags, brandy and whisky should be freely but wisely used. At 
the same time nourishment in the shape of eggnog, milk punch, and rice 
and barley gruels should be given as freely as the digestion will allow. 

The peripheral irritation and itching of the eruption are a cause of 
the fever in part, and produce much unrest and nervous irritability. 
The condition of the skin is therefore to be looked after and pitting 
prevented, if possible, by every means in our power, particular care 
being taken to prevent its development on the face. One of the means 
which has been recommended to prevent pitting is the use of flexible 
collodion, and anther application is glycerite of starch or simple cerate 
applied in a heavy coating. Some physicians recommend inserting 
the tip of a nitrate of silver stick into each vesicle as it ruptures, to 
prevent pitting. All of these measures are futile in most cases, and the 
use of collodion is probably harmful in some instances. The best 
application to use is made of 4 parts of salicylic acid to 100 parts 
of vaseline or cold cream. Sometimes anointing the entire body 
with sweet oil slightly phenolized (1 : 100) is useful to check irritation. 

If the mouth is sore, a mouth-wash of chlorate of potassium and 
water may be used, flavored with a little tincture of myrrh. (See 
Chlorate of Potassium and Stomatitis.) 

Disinfection, good ventilation, and the avoidance of much light are 
necessary. 

STINGS AND BITES. 

The stings of nearly all small insects depend for their activity upon 
formic acid, and are to be relieved by the use of dilute alkaline liquids, 
or, better still, by the application of ammonia, or, instead, an appli- 
cation of ordinary or flexible collodion may be made, or, if preferred, 
salicylic acid may be added in the proportion of 5 grains to the ounce 
(0.3-30.0), which is improved in its action by the addition of 1 part of 
mercury bichloride to 1000 of the collodion, or water of witch-hazel 
may be applied. Sometimes a solution of phenol, 1:100 or 1:50. 



916 DISEASES. 

when sponged over the parts exposed, not only relieves the itching of 
mosquito-bites, but also repels the mosquitoes. In other instances the 
stings are relieved and cooled by the use of dilute or pure vinegar. 
A useful application to prevent mosquitoes from biting is: 

1^— Olei citronellse f 3j (4.0). 

Alcoholis f 5j (4.0).— M. 

S. — Apply freely to the skin exposed. 

In snake-bite the best treatment consists in sucking the wound, 
as snake-venom, even if swallowed, is not poisonous. The part 
should then be freely incised, so as to cause the blood to flow freely, 
and immediately the wound should be filled with permanganate of 
potassium, and full doses of this drug given hypodermically about the 
wound, the salt being diluted three-fourths with water, and followed by 
full doses of ammonia given by the mouth. The secret of successful 
treatment consists, however, in the use of a ligature above the bitten 
spot and the opening oi the wound as soon after its reception as pos- 
sible, thereby preventing absorption of the poison. Antivenine and 
other antitoxins promise much for treatment in the future, 



STOMATITIS. 

This annoying affection is most commonly seen in children, and is 
characterized by the appearance on the tip and sides of the tongue, 
lips, and lining membrane of the mouth of small spots which some- 
times have a reddened zone around them, and which result in minute 
or large ulcers. 

The best treatment, if the kidneys are not acutely inflamed, is the 
use of the following prescription, which largely depends for its value 
upon the potassium salt used: 

1^ — Potassii chloratis . 5j (4.0). 

Tincturae myrrhae gtt. xx (1.3). 

Elixiris calisayse f §iij (90.0).— M. 

S. — Teaspoonful in water every four hours. 

As the chlorate of potassium is eliminated with the saliva, it not only 
does good when taken into the mouth, but is also active all the time 
that is is being eliminated. If the stomach is disordered, the same 
preparation may be used as a mouth-wash. Often constipation is 
present, and it should be relieved by salines or by rhubarb in the form 
of the aromatic syrup. Another remedy which is verv efficient in 
stomatitis is borax, used as a mouth-wash, in the strength of 10 to 15 
grains to 1 ounce (0.60-1.0:30.0) of water and honey, as follows: 
1$ — Sodii boratis g T xxx (2 0) 

Mellis depurati . . ..'.'.'. f Si'ij (12.0). 

Aquae destillatse q. s. ad fgiij (90.0).— M. 

S.— To be used on a swab or as a mouth-wash every four hours. 



STYES. 917 

This also may be given internally to adults in the dose of a teaspoonful 
(4.0) every three hours. 

in many cases peroxide of hydrogen in the proportion of 1 ounce 
(30.0) to 8 ounces (240.0) of water proves a valuable mouth-wash. 

When stomatitis is associated with pyorrhoea alveolaris the following 
is useful : 

Bj. — Acidi salicylici, 

Acidi benzoici aa gr. xv (1.0) 

Tincturae kramerise f oiss (6.0) 

Alcohol, absoluti foj (30.0).— M. 

S. — Teaspoonful to a small wineglassful of water as a mouth wash. 

If the liver is at fault and is torpid, nitromuriatic acid is useful. 
When the spots do not readily yield to treatment they may be touched 
with the tip of a stick of silver nitrate, which treatment, while it is 
momentarily painful, is very efficacious. 

Nearly always with this disease in childhood there is considerable 
fever, vomiting, and wakefulness at night, with fretfulness and crying 
during the day, and total refusal of food, not because hunger is absent, 
but because the food hurts the mouth and is rejected with a cry of 
pain as soon as it touches the lips. The food should be very soft milk- 
toast for older children, or milk with lime-water in it in large amount 
for infants fed by the bottle. If a child at the breast be attacked, the 
mother's nipple should be carefully washed with boric-acid solution 
after each nursing. A warm foot-bath at night is often necessary to 
produce rest, and 10 minims (0.60) of sweet spirit of nitre thoroughly 
diluted may be given with advantage to a child of one or two years. 
If the irritability of the nervous system is excessive, bromide of sodium 
or strontium in the dose of from 1 to 10 grains (0.06-0.60), according to 
age, three times a day, is of service, and may be added to the mixtures 
already named, or, better still, given alone, well diluted with syrup and 
water. 

After the attack tonics and a carefully selected diet are generally 
necessary. 

STYES. 

Styes consist in a localized inflammation of one of the glands in 
the margin of the lid or the surrounding connective tissue. Pain may 
be alleviated with frequently changed hot compresess (water 110° F.). 
Abortive treatment has been recommended and practised by massaging 
the swelling with a salve of the yellow oxide of mercury (2 grains 
to 3jj or by painting the surface with an ethereal solution of collo- 
dion, but such measures are of little avail, and an incision into the 
tumefied area to liberate the pus is promptly indicated. Associated 
conjunctivitis requires a boric-acid solution for its relief. It should, 
be remembered that styes indicate ill health; they often occur with 
anemic conditions in young women with menstrual disturbance. They 
most frequently appear in the subjects of refractive error, hence 



918 DISEASES. 

suitable glasses are required. When they tend to recur in crops the 
internal use of sulphurated lime has been recommended. 

In stubborn cases treatment with autogenous bacterial vaccines 
achieves excellent results. 

SUNSTROKE. 

Sunstroke — or, more correctly speaking, heat-stroke — is an affec- 
tion produced by exposure of the body to any form of high temperature, 
whether the source of heat be the sun, a furnace, or the radiation of 
heat from the earth. For this reason the condition may occur as readily 
at midnight as at mid-day. 

Heat-stroke is to be divided into two classes, in one of which excessive 
exposure to heat upsets the balance of the thermal mechanism of the 
body, so that fever (thermic fever) comes on; in the other the tempera- 
ture is lowered and forms the condition known as heat-exhaustion. 

The condition of thermic fever is very frequently seen, while heat- 
exhaustion is rare. 

The treatment of these two states is, of course, radically different. 
When a patient has thermic fever and comes under the care of the 
physician, the first thing to be done is to loosen the clothing — if 
possible, remove it — and if the pulse be bounding, the face cyanotic, 
and the heart laboring, to bleed him freely. At the same time intra- 
venous injection of normal salt solution should be freely resorted to, 
and this is particularly needful if the blood flows slowly and is very 
dark in hue. (See Intravenous Injection.) At the same time cold 
should be applied to the body, and particularly to the head, abdomen, 
back, and chest. The man should be stripped, laid upon a bed, 
which must be covered with a rubber blanket, and ice-water applied 
to the body by means of a sponge, or a piece of ice may be laid on the 
head, while another piece is rubbed over the rest of the body. While 
this is being done the surface of the patient's body must be thoroughly 
and briskly rubbed in order to bring the hot blood to the cooled skin. 

Care should be taken that the temperature, when it once begins to 
fall, does not drop suddenly below the normal and cause collapse. 
If the clinical thermometer in the mouth or rectum shows that the 
temperature has fallen to 101.5° or 100° F., the cold application should 
be stopped, and the patient allowed to lie on a bed, covered only 
with a thin sheet. The bodily temperature must be constantly watched, 
as it will probably bound up again in a few minutes, and require 
the application of more cold, used with the same care. This second 
rise is due either to the disorder of the nervous mechanism of heat- 
production and dissipation, or to the fact that, while the surface of 
the body is cooled by the ice, the innermost viscera are still in high 
fever and rapidly heat the surface as soon as the ice is taken away. 
Antipyretics have been found to be almost useless in the hyperpyrexia 
of sunstroke, and are not to be relied upon. 



SYPHILIS. 919 

After the fever has been reduced permanently the danger is not all 
passed, and it is the greatest mistake to discharge a patient as cured 
at this time. After two or three days it is very common for a menin- 
gitis to develop, accompanied, it may be, by little or no fever, but 
characterized by violent darting headache, which is made worse on 
lying down or on sudden movement. The treatment of this state 
must be bold, and venesection is the only safe method of obtaining 
relief, although vascular sedatives, such as veratrum, may be employed. 
The bleeding should be copious enough to impress the circulatory 
system to some degree, and may be done by opening any of the 
prominent veins in the arm. (See Venesection.) Sometimes a violent 
attack of epistaxis saves the man's life when it would have been lost 
through the ignorance of his attendant. If life is preserved without 
vascular depletion, secondary changes in the brain may ensue and 
produce hemianopsia, optic atrophy, imbecility, or insanity. Quinine, 
salicylic acid, and similar substances are all contraindicated under 
these circumstances, because of the congestion of the meninges to which 
they predispose by their physiological effects. 

The treatment of heat-exhaustion consists in the use of heat instead 
of cold, in order to restore the bodily temperature. Just here, how- 
ever, must be uttered a word of warning — namely, that the mere fact 
that the skin is cold does not prove the case to be one of heat-exhaus- 
tion, since a rectal thermometer may show the central or real tem- 
perature of the body to be that of hyperpyrexia. Of course, such a 
case should not receive hot, but cold, rectal injections if the symptoms 
require it. 

The bodily heat in heat-exhaustion is to be raised by placing the 
patient in a bath at 105° to 110° F., or by the use of hot bricks or bottles, 
care being taken that they do not burn the patient. The bodily tem- 
perature should also be watched, lest the other extreme of heat be 
reached. 

Cases of heat-exhaustion are not so apt to have meningitis as are 
cases of sunstroke, but they are generally slow to convalesce, and 
require tonics and careful watching for a long time. Indeed, in many 
instances the system seems to receive a shock from which it takes 
several weeks or months to recover. 



SYPHILIS. 

In so far as the choice of drugs is concerned, the treatment of syphilis 
is exceedingly simple; mercury and salvarsan are the specifics and 
should be employed in all stages of the disease; during the tertiary 
period or in the presence of tertiary manifestations, particularly those 
of the cardiovascular system, they may be supplemented by the iodides 
or iodine. (See Mercury and Salvarsan.) 

A first essential in the successful treatment of syphilis is the condi- 
tion of the general health. This implies where needful such modi- 



920 DISEASES. 

fications in habits, diet, and mode of life as will best assure this end. 
Aside from the general feeling, capacity for work, and enjoyment of 
food, the gauge of good health is afforded by the body weight. If in 
the course of syphilitic treatment this steadily diminishes, it is a fairly 
reliable index that either the treatment is inefficient or too vigorous. 
In the former case characteristic lesions of the infection are likely to 
appear. In the latter case a rest from medication will be followed 
by a betterment in the general condition and a gain in weight. Arsen- 
ical and mercurial treatment, if injudiciously pushed, so unfavorably 
affects metabolism as to lower vital resistance to infection and thus 
destroys the means of cure on which greatest reliance is justly placed. 
During the course of treatment it is always wise to give periods of rest. 
As a means of stimulating general metabolism, absorption, and elimi- 
nation hot baths are of great service, and should supplement the specific 
treatment particularly when the latter does not cause prompt and 
permanent disappearance of specific lesions. (See Salvarsan.) 

The salvarsan and mercury treatment should be instituted the 
moment the diagnosis of syphilis is assured by the finding of the 
specific micro-organism in the primary lesion and should be continued 
with intermissions for four years ; in the absence of symptoms mercury 
should be given spring and fall thereafter for life. The dose of the 
specific varies in accordance with individual susceptibility and the 
virulence of infection. The term "proper dosage" implies absence of 
specific manifestations and a condition of good health. 

It is now assumed that a syphilitic infection seen in its primary 
or early secondary period may be cured. This is accomplished by six 
intravenous injections of salvarsan. neosalvarsan, arsenobenzol or 
similar preparation, given at intervals of not less than three nor 
more than seven days, in doses so moderate that general health and 
renal secretion are not disturbed and no symptoms of arsenical poison- 
ing are produced (approximately 0.4 salvarsan) and by the adminis- 
tration of interrupted courses of mercury so graded that there does 
not result therefrom fetor of the breath, colicky pain, or albumin and 
casts in the urine. 

The mercurial treatment is taken after the second or third arsenical 
injection, preferably in the form of inunctions, for which purpose may 
be used either mercurettes, each containing 30 grains of metallic 
mercury finely subdivided and disseminated through a mass of cocoa 
butter; or mercurial ointment. The patient is instructed to rub at 
night after taking a hot bath one mercurette, or 1 dram of mercurial 
ointment, into the skin covering the lateral aspect of his chest, 
abdomen and hip. This for fifteen minutes. Thereafter to put on a 
moderately thick undershirt and over this his ordinary night garments. 
He bathes the following morning, removing the undershirt and putting 
on his ordinary garments. This treatment is repeated the following 
night, the skin of the opposite side of the body being employed. The 
third night the front of the abdomen; the fourth night the region of the 



SYPHILIS. 921 

back. The same undershirt is put on each night. It is not washed, its 
value increasing with its impregnation with mercury. 

These treatments are given usually in series of six, with three days' 
rest, until not less than four, nor more than eight courses have been taken . 

If the treatment is efficient and properly graded, there will be no 
symptoms of a toxic effect of mercury, he will feel well and will retain 
weight or even gain it. 

On the first sign of mercurial intoxication, which may be fetor of 
the breath or gastro-intestinal disturbance or albuminuria, not other- 
wise accounted for, mercury should be stopped until the toxic symp- 
toms entirely disappear. Thereafter the doses should be diminished 
and the intervals of rest increased. 

If the patient's condition be steadily improving the dosage may be 
cautiously increased. 

After the course of arsenic and mercury as above outlined, there 
should be a rest of three months, whereupon the Wassermann reaction 
is taken. If this prove negative a further rest of three months and a 
second Wassermann. Thereafter with negative findings a rest of six 
months and a third Wassermann; and thereafter a rest of a year and a 
fourth Wassermann. 

If the Wassermann prove positive the treatment should be repeated, 
but with less severity, and thereafter for life the patient should take a 
spring and fall mercurial treatment, preferably by inunctions, four 
to six series of six, followed by three days' rest after each six. 

If the Wassermann be negative but clinical manifestations of the 
disease develop upon the surface, in the form of cardiovascular lesions, 
or in the direction of the central nervous system, there should be a 
repetition of treatment as vigorous as was employed at the beginning 
of the infection, except if nervous or cardiovascular lesions be well 
advanced or accompanied by marked deterioration in health, the 
treatment should be inaugurated by mercury and the arsenic given in 
small doses and in cardiovascular cases should be supplemented by 
iodides. 

When patients present themselves with florid and well marked 
secondaries, or w T ith pronounced symptoms of cerebrospinal syphilis 
the arsenical treatment should be preceded by mercury administered 
with due consideration of its possible toxic effects. 

If inunctions are impracticable or absolutely objected to by the 
patients they may be substituted by hypodermic injections or mouth 
administration. As to mouth administration the protiodide is usually 
preferred, because in practice it has been found one of the most satis- 
factory of all preparations. Where this form of mercury is not well 
borne the physician should at once employ some other salt; the 
bichloride, in y^-grain (0.005) doses three times a day, is efficacious. 
Blue mass will often act favorably when other preparations cannot be 
tolerated. Its combination with iron is desirable, and the following 
formula represents one of the most valuable of the antisyphilitic pills: 



922 DISEASES. 

R — Massse hydrargyri gr. xxx (2.0). 

Pulveris ferri chloridi gr. xv (1.0). — M. 

Fiaut pilulse No. xii. 

S. — One three times a day. 

Where mercury cannot be administered by the mouth it may be given 
by hypodermic injections. The preparation of choice may be either 
soluble or insoluble. The soluble preparations are rapidly absorbed 
and hence give a certain degree of accuracy of dosage. They are open 
to the objection that they must be frequently repeated, namely, every 
day, until the indicated course is completed. One of the best and 
simplest of the soluble preparations is that recommended by Hebra. 

In the United States the hypodermic administration of mercury is 
limited to those few cases which do not seem to respond to the drug 
when given by the mouth or by inunction. The absorption is extremely 
irregular and may be explosively rapid or indefinitely postponed. 
Although many preparations of mercury have been lauded as most 
efficacious when used hypodermically, one of the best formulas seems 
to be that recommended by Hebra. This consists of a solution of 1 
per cent, of bichloride of mercury in a 0.6 per cent, sodium chloride 
solution; the resulting mixture is perfectly clear and is readily prepared. 
If it becomes turbid, it should be thrown away. Rigid antiseptic 
precautions must be observed, as abscess-formation is not uncommon. 
One injection is given daily, from | to J grain (0.01-0.02) of the sub- 
limate being administered. The nates are selected as the seat of the 
injection, the solution being driven well into the muscles of each side 
every other day. Twelve to twenty -four injections constitute a course, 
after which there should be a period of rest of from six to twelve days. 
(See Mercury Salicylate.) 

The employment of the insoluble preparations of mercury is irregu- 
larly painful, and is at times attended by a continuous absorption 
which may produce severe and even fatal ptyalism and renal irritation. 

Salicylate of mercury is the most popular of the insoluble prepara- 
tions, given in 10 per cent, albolene suspension. The initial dose is 
10 minims, repeated at intervals of three to seven days. Twenty, 30, 
or 40 minims may be employed in accordance with effect upon the 
lesions and the general health. The drug is usually given in series of 
6 or 12 doses, followed by rest of weeks or months in accordance with 
the condition of the patient. 

In long-standing cases, exhibiting a persistent Wassermann reaction 
without clinical symptoms, salvarsan has not proved itself particularly 
serviceable, even from the standpoint of turning a positive Wasser- 
mann to a negative one. In combating the so-called parasyphihtic 
phenomena (locomotor ataxia and paresis) it has apparently been of 
no avail. Advanced degenerative lesions of the central nervous system 
and profound depression of the renal function constitute contraindi- 
cation of its use. (See Salvarsan.) 

The tonic and general treatment of syphilitic cases must not be 



TETANUS. 923 

forgotten; fresh air, exercise, bathing, careful diet, regular living, all 
must be enjoined. Moreover, in certain cases where there is marked 
anaemia or physical weakness cod-liver oil, stimulants in moderation, 
compound syrup of the hypophosphites, and other tonic and nutritive 
courses of treatment must be carefully administered.- 

Although the treatment of an ordinary case of syphilis is simple and 
satisfactory in its results, it must be remembered that there are malig- 
nant forms of the disease, attacking by preference feeble and cachectic 
individuals, running a rapid and virulent course, unchecked, nay 
aggravated, by specific treatment, and responding feebly, if at all, to 
the most careful hygienic and tonic regimen. In many such cases 
salvarsan or neosalvarsan is the only hope. (See Salvarsan, Part II.) 

The repetition of courses of salvarsan and mercury should not be 
stopped until not only the blood but the cerebrospinal fluid as well, 
have given negative Wassermann reactions in tests made after intervals 
of many months. It is important to remember that the free use of 
alcoholic drinks may cause a negative Wassermann test. The luetin 
test should also be used. 

TETANUS. 

Immediately after the receipt of a suspicious wound, and before 
tetanic symptoms develop, the point of infection should be widely 
incised, washed clean, swabbed with a 3 per cent, solution of iodine, 
and then with peroxide of hydrogen. After this the wound should be 
loosely packed with gauze wet with iodine solution. 

The treatment of tetanus after the symptoms have developed is quite 
independent of its causation, so far at least as drugs are concerned, 
and, aside from the use of antitetanic serum, is virtually identical 
with that of strychnine-poisoning, to which the reader is referred. 
(See Xux Vomica.) The value of the antitoxin for tetanus depends 
very largely upon how early it is given. When the disease has once 
developed, it cannot be of much use, but it should always be tried. 
It may be given in three ways: intravenously, into the cerebrospinal 
fluid around the spinal cord by intraspinal injection (see Tropacocaine), 
and intraneurally, as it has been found that the infection travels along 
the nerve trunk. The intraneural method and the intraspinal injection 
meihod are the measures which should be resorted to whenever it is 
certain that infection by the tetanus bacillus has taken place, and 
they are particularly needful if the symptoms have already developed. 
In these cases the point of injection into the nerve should be well above 
the wounded area to head off the poison, as it travels up the nerve 
trunk. A prophylactic subcutaneous and intraneural injection of 
tetanus antitoxin should always be given when the injury has been 
produced by the explosion of the toy pistol, as this provides an almost 
sure preventive of the disease. (See Antitoxin, Part III, and Chlore- 
tone and Magnesium Sulphate, Part II.) The diet should be most 
nourishing. Continuous immersion in hot water may be tried. 



924 DISEASES. 

TONSILLITIS. 

Inflammation of the tonsils occurs in three forms: superficial ton- 
sillitis, in which the mucous membrane covering the tonsils becomes 
inflamed through extension of a pharyngitis; follicular tonsillitis, in 
which the follicles are chiefly involved and pour out an excessive 
secretion, and, finally, true tonsillitis, in which the gland itself suffers 
from severe, widespread inflammation phlegmonous in type. In all 
these forms the treatment to be instituted at the beginning is prac- 
tically identical. The bowels should be opened by a saline purgative, 
which in some cases should be preceded by small doses of calomel, 
-be diet should be liquid and nutritious, and a fever and diuretic mix- 
ture should be given freely as follows: 

1$ — Tincturse aconiti npd vel lxxx (2.6-5.3). 

Spiritus setheris nitrosi f§j (30.0). 

Liquoris potassii citratis . q. s. ad f §iij (90.0). — M. 
S. — Dessertspoonful every three hours to a child of ten years; or a tablespoon- 
ful (15.0) to an adult. 

The best local treatment is to cleanse the tonsil with hydrogen 
peroxide and then paint it with pure guaiacol on a cotton applicator, 
or to apply powdered aspirin in the same manner. The second of 
these applications is very painful for a moment. 

Small doses of biniodide of mercury are sometimes useful to abort 
an attack of acute tonsillitis, ^ho grain (0.0003) every hour in water 
for four or five hours being the amount usually employed. 

Externally, an ice-bag should be applied about the throat, and as 
soon as the purgative has acted and the fever is reduced by the mix- 
ture just given, full doses of the tincture of ferric chloride should be 
administered (20 minims [1.3] every three or four hours), in plenty of 
water, which preferably should be Vichy or one of the good lithia waters. 

In some instances hot fomentations about the neck and hot gargles 
seem to be more beneficial than the use of ice. Often a mild antiseptic 
gargle of phenol (1 : 100) in water will relieve the pain and the fetor. 

Chronic tonsillar enlargement does not require operation as often as 
is thought. Tonsillectomy is of graver import than appears at first 
sight. Because tonsils are chronically enlarged and protruding that 
does not indicate operation, even if they are ragged. I agree with 
French, of Brooklyn, who says, " While all extensively diseased tonsils 
should be enucleated, it is probably safe to say that 80 per cent, of 
enlarged tonsils do not contain foci of infection, and therefore do not 
need to be completely removed, and, indeed, unless obstructive to voice 
or respiration, do not need to be removed at all." They should be 
removed if they are the seat of septic foci, even if they do not protrude 
or if subject to repeated abscess or if they are the cause of cervical 
adenitis. Their removal not only relieves local disease but diminishes 
the danger of rheumatic infection and of endocarditis. Local appli- 
cations are rarely of much benefit. 

As a rule children under six years of age should not have the tonsils 



TUBERCULOSIS. 925 

removed, but in some cases infected crypts can be opened up and 
drained. 

TUBERCULOSIS. 

Tuberculosis affecting any part of the body is a manifestation of the 
fact that vital resistance has been decreased, for if not infection could 
not have taken place. The whole point at issue in cases of tubercular 
infection, as in all infections, is the building up of vital resistance to 
such a level that the battle between the invading bacillus and the 
cells of the body can be waged with victory for the cells, and as soon 
as they are able to cope with the infecting agent there is at once 
formed a protecting wall of inflammatory lymph which surrounds the 
area infected and protects the rest of the body from the bacilli that 
it contains. The means by which the greatest degree of vital resist- 
ance are obtainable is an outdoor life with exposure to as many hours 
of sunshine as possible and an abundance of fresh air. No drugs can 
equal the value of these outdoor agencies. (See Climate, Part III.) 

The second point to be borne in mind is that no drugs in tuberculosis 
equal good food if it is well digested and taken in full amount, and he 
who disorders the digestion by drugs is doing his patient more harm 
than good. A good cook is a better friend to a tuberculous patient than 
a good druggist. (See Diet, Part III.) 

Cases of pulmonary consumption follow, rudely speaking, four well- 
defined lines. A very early stage sometimes comes to the care of the 
physician, and it is that in which the following history is given 
or a similar story is elicited. A patient, previously strong and well 
or of poor health, as the case may be, begins to lose vivacity. Life 
becomes a burden and exercise is distasteful. A slight daily chill and 
fever develop in morning or evening, and the physician who is careless 
treats the case as one of mild malarial poisoning. Careful examina- 
tion, however, will show an area in the lung, generally near the apex 
on one or both sides, where slight prolongation of expiration with a 
harsh inspiratory sound is heard, and where percussion will give 
impaired resonance or dulness. In other words, the first stage of 
phthisis is present, and the physician must resort at once to those 
active measures for the patient's relief which will be considered 
shortly. 

In another form a chill, a sweat, a loss of flesh and vigor, with, 
more prominent than all, a hard cough, sudden in its onset and rap- 
idly becoming excessive with profuse expectoration, are the dominant 
symptoms. The wasting is extreme, the sweats are constant, and 
death may come in a few weeks. This is the form known as "gallop- 
ing consumption." 

The third variety is ushered in by a gradual loss of vigor or a sensa- 
tion of being a little unwell, or this form is brought before the patient's 
mind by a sudden acute hemorrhage, or several hemorrhages rapidly 



926 DISEASES. 

succeeding one another. This variety passes along its course with 
varying rapidity. Death very rarely is due directly to the hemorrhage, 
although a secondary pneumonia may bring the end. In most cases 
the disease keeps on for months and the case dies from exhaustion. 

Last of all, the fourth class is made up of persons who gradually 
pass from bad to worse: First, they "catch a cold," which hangs on 
longer than it ought, and, as soon as they are well, this is followed by 
another one, which is found more difficult to cure, until finally there 
is always a cough. Soon wasting comes on, strength is lost, and a 
long period of months ensues during which the progress of the case is 
now slow, now fast, the condition now better, now worse, until death 
ensues from wasting, pneumonia, or some other complication. 

These forms and stages have been roughly outlined so that a dis- 
cussion of their treatment might be taken up with a clear idea of what 
is to be done. 

When a patient exhibits those physical signs which have been 
given as evidences of the early beginnings of phthisis, the physician 
should institute certain hygienic and medicinal measures. If the 
individual be earning a livelihood by following some confining occu- 
pation, this occupation must be given up and one undertaken which 
is carried on in the open air and yet not accompanied by too great 
exposure. Even if exposure is incurred, it is often better than the 
occupation previously followed: thus, if the patient be a bookkeeper, 
a printer, or a bookbinder, or a clerk kept much at a desk in an ill- 
ventilated room, a few wettings in the rain will do little or no harm 
if the patient is properly protected by the wearing of flannel shirts, 

which, when wet, are changed as soon as labor ceases, as under these 
circumstances the danger of catching cold is at a minimum. (See 
Climate, Part III.) The sleeping-room should be used with all the 
windows open or if possible a tent life is to be followed. 

The medicinal measures to be carried out in all cases of phthisis, 
except that known as the galloping form, are not numerous if we con- 
fine ourselves to the modes possessing any real value. For many 
years cod-liver oil has been sadly abused in the management of these 
cases, and has been given at all stages, owing to ignorance of its proper 
use. The writer believes that the following rules are never to be 
departed from: 

1. Never use cod-liver oil if it disturbs digestion. 

2. Never use it if fever is active. 

3. The use of cod-liver oil when rapid degenerative changes are 
occurring in the lung may be distinctly harmful, as it is not of any 
service, disorders the digestion, and destroys the appetite. 

4. Its best employment is in the earliest stages of the disease and in 
chronic fibroid phthisis. 

5. If the patient can take and assimilate cod-liver oil in addition to 
plenty of good food give the oil, if not, stop it. 

When the oil is used, it should be given as directed in the article on 
Cod-liver Oil. 



TUBERCULOSIS. 927 

A remedy of some value as a palliative is creosote. Many cures 
have been claimed from its use in the early stages of phthisis, and 
it has been highly lauded by a number of European clinicians. In 
the author's experience it is of value only when the presence of bron- 
chitis requires the use of an expectorant. If it disorders digestion 
it is harmful. The opinion declared by Strumpell expresses so well 
the thought which the author was about to write when he read Striim- 
pelFs article that his words are here given: "Taking it all in all, we 
find that creosote, even in large doses, has no injurious effect on 
tuberculosis. At times we notice an apparently favorable symptomatic 
effect. AYe failed, however, to observe any real influence exerted by 
creosote on the progress of the disease." (See Creosote.) When creo- 
sote is used internally it may be given in the following formula: 

]$ — Oreosoti (beechwood) . . V . gtt. xxxij vel foj (2.0-4.0). 

Tincturae gentianae foj (30.0). 

Alcoholis f§j (30.0). 

Villi albi q. s. ad f §iv (120.0).— M. 

S. — Teaspoonful (4.0), in water or wine, three times a day. 

Better still, creosote may be given in ascending doses (1 minim extra 
each dose) in milk or wine. 

Often a 1-minim (0.06) dose three times a day may be increased to 
5 minims (0.3) in the same period with advantage. Sometimes 1 or 2 
minims (0.06-0.12) in capsule are as useful as the formula just named. 
(For methods of administration see Creosote; also, see Guaiacol and 
Creosote Carbonate.) 

Creosote may also be inhaled in the spray from a steam atomizer or 
by means of an inspirator fitted over the nose and mouth and made of 
perforated zinc with a sponge at the edge to hold the drug. A very 
good method is to wet the sponge with creosote, alcohol, and water, 
equal parts, or to use the creosote alone if coughing is not too severe. 
Another useful mixture consists of equal parts of terebene, iodide of 
ethyl, and chloroform. This last mixture is most useful when the 
secretion is tough and tenacious, and should not be used in the pres- 
ence of acute irritation due to inflammation. Such inhalers are very 
cheap, not easily broken, and readily worn. (See Inhalations.) 

If the cough is excessive, a little spirit of chloroform placed on 
the sponge of the inhaler will often relieve it, or a mixture of mor- 
phine and wild-cherry bark may be given as follows : 

I£— Morphinae sulphatis gr. j vel ij (0.06-0.12). 

Syrupi pruni virginianae . . . . f §iij (90.0). — M. 
S. — Teaspoonful (4.0) every three hours. 

Or the following: 

1$ — Spiritus chloroformi f^ss (16.0). 

Morphine sulphatis gr. j vel ij (0.06-0.12). 

Syrupi pmni virginianae .... foiij (90.6).— M. 
S. — Teaspoonful (4.0) every four hours. 

In still other cases 2 to 10 minims (0.1-0.60) of a good fluidextract 
of cannabis indica, or J to J prain (0.008-0.015) of the solid extract. 



928 DISEASES. 

will act with surprising benefit and stop the cough. Heroin in small 
doses is also useful when there is an idiosyncrasy to morphine. 

Very often during the course of phthisis localized spots of pleuritic 
inflammation develop which give rise to pain. The best treatment is 
to apply a small blister or to paint the spot with iodine. 

(For the treatment of Haemoptysis see Hemorrhage.) 

Laryngeal phthisis, one of the most serious complications of this 
disease, is best prevented by ordering the patient to inhale the steam 
arising from boiling water which contains corrosive sublimate in the 
proportion of 1 : 10,000. If a proper watch is kept for evidences of 
a general mercurial effect, and this measure stopped at once when 
tenderness of the gums appears, no danger exists. Before the inhala- 
tion takes place a spray of cocaine (4 per cent, solution) should be 
thoroughly used. 

The treatment of laryngeal phthisis itself is various. The best 
method is that in which lactic acid is used. By the aid of a laryngeal 
mirror and a cotton applicator a 10 per cent, solution of lactic acid is 
applied to the spots which are involved. As this is generally quite 
painful, cocaine solution should first be used. Gradually the strength 
of the lactic-acid solution should be increased to 60 per cent, if the 
weaker solutions do not check the disease. Very valuable results have 
been obtained by this method. 

The second method in point of value is that of iodoform insuffla- 
tions. A powder of iodoform alone is too light for satisfactory pro- 
pulsion into the larynx, and powdered talc should be added to it in 
small amount, with y 1 ^ grain (0.004) of morphine to each drachm (4.0) 
of iodoform. The odor is generally disagreeable to the patient, but if 
a cocaine spray be first applied to the fauces and the operator is skilful, 
very little coughing is produced. As iodoform is a local anaesthetic, it 
relieves the pain in the larynx, acts as an antiseptic and alterative, and 
is peculiarly obnoxious to bacillus tuberculosis. 

Camphoric acid in 20- to 30-grain (1.3-2.0) doses is the best internal 
remedy for treating night-sweats. (See Camphoric Acid.) 

When the night-sweats are very profuse, hypodermic injections of 
atropine in the dose of yj-g- to j^-q- grain (0.0004-0.0006) are useful in 
some cases, and the efficiency of this treatment may be increased by 
the use of an alum sponge-bath at bedtime. A solution of alum, 10 
to 20 grains to the ounce (0.60-1.3:30.0), may be sponged over the 
body, or sulphuric acid may be added to water in the proportion of 1 
drachm to the pint (4.0-480 mils.), and used in the same way as the 
alum solution. Formaldehyde solutions may also be used. 

Sulphuric acid is often given internally with advantage in these cases 
of sweating. 

Reference should be made to the treatment of pulmonary tubercu- 
losis by artificial pneumothorax. This method is based on the view 
that the collapse and rest of the lung will aid in arresting the process. 
It is applicable only in those cases in which the lesions are almost solely 



TUBERCULOSIS. 



929 



on one side, since it is necessary that the lung not compressed shall com- 
pensate for the work of the collapsed lung, and that there shall not be 
pleural adhesions which cause the lung to adhere to the chest-wall. The 
fact that the disease on one side is very far advanced does not contra- 
indicate this plan. Indeed, some of the best results have been obtained 
in cases so far gone that any method was acceptable to the patient. 
If the pneumothorax is properly induced the method is not dangerous 



Fig. 143. 




Robinson's apparatus for'artificial pneumothorax. Two bottles of 2000 c.c. capacity are em- 
ployed. One is stationary and filled with water containing 2 drachms of pyrogallic acid to take 
up any oxygen which may enter in conjunction with nitrogen. Nitrogen gas is then forced into 
stationary bottle (.4), displacing the water back to bottle B. At completion of this displacement 
the apparatus is ready for use. On opening certain cocks the water in bottle B replaces the 
nitrogen in bottle A, gradually filling it. The difference in the water levels of the two bottles 
represents the pressure under which the nitrogen is injected, the rapidity of its injection being 
regulated by the size of the opening in any one of the cocks. When bottle B is full the maxi- 
mum pressure is obtained, amounting to about 14 c.c. of water. As the water levels approach 
one another bottle B may be raised, thus maintaining the pressure until most of the nitrogen 
has been displaced, when the pressure is necessarily reduced. With this hydrostatic mech- 
anism the pressure may be varied at will, never attaining the dangerous limit. The arrange- 
ment of cocks d, e, and / corresponds to the substitution of a three-way cock at point g. 
In other words, with cock d closed and e and /open, a direct connection is established between 
the thoracic cavity and the manometer. With cock/ closed and c, d, and e open, connection is 
made between the confined nitrogen and the manometer, thus recording the pressure repre- 
sented by the difference in water levels of bottles A and B. With cock e closed and all others 
open the nitrogen passes directly from bottle A into the pleural cavity. 

The results which accrue usually consist in prompt diminution of 
cough and expectoration and a decrease in the systemic manifestations 
of the disease. So, too, it has been found a most efficient means of arrest- 
ing profuse pulmonary hemorrhage. If the other lung is in fairly good 
condition there is little dyspnoea. This treatment is contraindicated if 
adhesions so fix the diseased lung that it cannot be made to collapse. 

Several methods of introducing the gas are resorted to. The simplest 
59 



930 



DISEASES. 



is that by Forlanini. This consists in introducing a small aspirating 
needle, preferably in the fifth or sixth intercostal space, in the mid- 
axillary line or anywhere the pleura is free, the patient lying on the 



Fig. 144. 




Floyd's modification of Brauer's needle for use in pneumothorax therapy 

unaffected side. Through this needle is slowly passed pure nitrogen 
gas to the extent of from 200 to 300 mils., but it is not so much a ques- 
tion of the amount of gas as of the pressure exercised. (See below.) 



Fig 145. 




Showing the degree to which the left lung may be compressed by artificial pneumothorax 
within nineteen days. (Amrein and Lichtenhelm.) 

About this quantity is injected on alternate days until complete collapse 
of the lung is gradually induced. The degree of collapse can be esti- 
mated by ordinary methods of physical diagnosis and by the aid of the 
^-rays. Nitrogen gas is used because it is less rapidly absorbed than 



TYPHOID FEVER. 931 

atmospheric air, and so better maintains the pressure. The gas should 
be warmed to body temperature before it is injected. A U-shaped 
glass tube partly filled with water, and provided with a scale in milli- 
meters of displacement, should be connected with the tube, which car- 
ries the gas from the container to the chest. The branch running to 
this U-shaped tube should be provided with a two-way cock, as by 
this means the negative pressure in the chest cavity after the needle 
is introduced can be measured and the positive pressure of the gas 
delivered to the chest can readily be estimated. The negative pressure 
fluctuations caused by respiration should equal about 10 Mm. or more 
of displacement in the manometer. If such fluctuations do not occur 
the injection is contraindicated, since their absence indicates that the 
lung is bound to the chest-wall by adhesions and cannot be made to 
collapse. The positive pressure of the gas should be from 40 to 250 Mm. 
but less than 250 is better. After the needle is introduced it should be 
moved up and down to determine that its point is not engaged in the 
lung tissues. 

Even when nitrogen gas is used so much as 80 to 100 mils, may be 
absorbed in each twenty-four hours and, therefore, repeated injections 
must be made to maintain the collapse. 

As a rule the pressure must be continued several months before the 
lung heals in its collapsed form. Often when the treatment is stopped 
after some months, and when the patient is so greatly improved that it 
is thought wise to stop, the lung will expand slightly. 
• Finally, it is manifest that the most rigid rules of asepsis must be 
constantly adhered to, as a pyopneumothorax may readily be induced 
through errors in the technique. 

It need hardly be added that this plan is to be instituted in only a 
very limited class of cases, as, for example, those in which the cough is 
exhausting, haemoptysis is repeated, and the lung is suffering from fairly 
widespread and advanced lesions which are tending to break down 
and form cavities; in other words, in cases not at death's door but 
otherwise hopeless cases. 

TYPHOID FEVER. 

Any attempt to review the various forms of treatment of the disease 
known as typhoid fever is absolutely impossible, owing to the very 
numerous theories and practices put forward by various clinicians. 
What is said under the general heading of Fever and under the con- 
sideration of Cold, Part III., and also under Antipyrine and Acetanilide, 
gives sufficient information as to the treatment of febrile movements, 
and the care of the patient beyond this point in nearly all cases depends 
upon the severitv of the attack. 

Before going farther, however, the writer desires to insist very 
strongly upon one fact — namely, that a case of typhoid fever is not 
curable in any degree. Xo remedy yet found, except it act through 
the prevention of complications, can shorten the course of the disease. 



932 DISEASES. 

We can only guide the patient safely to health when the storm of dis- 
ease comes on, and we cannot stop the storm. 

Not only should the facts of the last paragraph be carefully borne 
in mind, but the physician must also remember that he is treating an 
exhausting disease — not a disease which runs a violent course for a 
few days and strands the patient sick and weak, but convalescent, 
upon the shores of health, but one in which, after sapping the strength 
for weeks, some sudden intercurrent malady or accident may ensue 
which will speedily kill him if every grain of strength is not preserved 
for the struggle. The physician should always put every case in which 
there is a suspicion of typhoid fever to bed at once, and keep the 
patient there until the disease has passed or fails to develop. Every 
muscular movement unnecessarily made is a waste of force, and, in 
consequence, everything should be done for the patient, and not by 
him. A bed-pan should always be employed, the patient not being 
allowed to sit erect upon a commode. 

Remembering, too, that a typhoid fever patient is subjected to pro- 
longed wasting fever and toxamia for many days, his nutrition should 
be maintained by the use of a nourishing diet easy of digestion. In 
addition to milk he should also receive one or two soft-boiled eggs 
each day, arrowroot and perhaps thin corn starch, provided they agree 
with his digestive powers. If diarrhoea is not present, broths may be 
given, but it must be recalled that Brieger has shown that typhoid 
bacilli do not readily reproduce themselves and their poisons in pep- 
tonized or well-digested milk, but do so very actively in meat-broths or 
jelly which has not been acted upon by the digestive juices. Milk 
diet is therefore evidently better than a broth diet in typhoid fever, 
and we once more are able to explain an empirical fact by a scientific 
discovery. There is no reason for using liquid instead of solid foods, 
except the difficulty of digesting the latter. (See next page.) 

Alcohol has been used in all stages of typhoid fever as a stimulant, 
as a giver of force to the system, and as an aid to digestion, but its real 
value is found when actual depression exists. A very large part of 
the profession believe that the mere presence of an abnormally high 
temperature contraindicates the use of aclohol. Mere high tempera- 
ture does not do so, however. High temperature of a sthenic type, 
with a full, tense, bounding pulse and all the signs of a disease at- 
tacking one in the full vigor of life, may preclude its use; but in the 
high temperature of advanced typhoid, with the marked asthenia 
often present in that stage, alcohol should be given whenever the 
heart-sounds are feeble. Under these circumstances the tissues 
which the man can afford to lose are gone, and much of his vitality is 
greatly encroached upon: the alcohol yields force to the body, and is 
burnt up in great part, keeping the flagging heart pumping the blood 
through the lungs and systemic circulation, when otherwise the circu- 
latory depression would result in hypostatic congestions, if not in more 
widespread circulatory disorder. Alcohol acts rather by restoring the 



TYPHOID FEVER. 933 

equilibrium of the circulation and giving force to the body than by a 
direct stimulant effect. It may also increase the bacteriolytic power 
of the blood. In those cases in which a temporary loss of heart-power 
is due to hemorrhage or to some sudden severe depression, alcohol is 
one of the remedies to be employed — in a hot and concentrated form. 
(See Alcohol.) 

A no less useful and valuable result obtained by the use of alcohol 
in the later stages of exhaustive fevers is the part that it plays in aiding 
digestion. The writer has elsewhere defined the difference between 
the influence of alcohol in the artificial digestion of the test-tube and 
that occurring in the stomach. Aside from experimental evidence, 
every-day experience has taught the gourmand that alcohol, in a fairly 
concentrated form, enables him to digest an amount of food which 
under ordinary circumstances would remain unchanged in his stomach. 

The physician ought not to use alcohol as a routine measure in 
every case without a rational idea of why he does so, nor without a 
clear idea as to what indication is met by its use. In many cases it is 
not needed at any time. 

That alcohol may be misused and cause great harm is, of course, 
known to every practitioner of medicine. So long as it reduces the 
temperature and lowers the rate of the pulse, causes a moist skin and 
tongue, and quiets nervous twitchings, it does good, and only up to 
this point is it to be employed. 

The treatment which is used by the author for many years in his 
wards at the Jefferson Medical College Hospital has given him results 
which the application of other methods has failed to give, and is as 
follows : 

As soon as the patient enters the house he is washed or bathed and 
placed in bed, and required to remain there. He is assured that the 
more quietly he lies the more mild and safe will be the course of his 
attack, and is made to use a bed-pan and urinal, and never allowed to 
get up. He receives several small doses of calomel, followed, if the 
bowels are not moved, by a mild saline purge, such as a Seidlitz powder. 

Whenever the temperature reaches 102° F. he is given cold sponging 
with friction or an ice rub. This is essential. (See Cold, Part III.) 

I am one of those who are firmly convinced that for many years 
we have been making a grave mistake in confining patients suffering 
from typhoid fever to a purely milk diet. We must recollect that 
the average adult requires at least 2500 calories a day for normal 
existence, and as each quart of milk represents only about 500 to 600 
calories, it is evident that for a patient to receive the total number 
of calories required for the maintenance of his body he must drink 
not less than four and a half quarts of milk a day. These facts further 
impress us with the utter inadequacy of the pure milk diet in this 
disease. Nor can we help appreciating the fact that we are overloading 
the organs of absorption and elimination with an excess of fluid, which 
certainly cannot be advantageous, although of course an excess of liquid 
in typhoid fever is preferable to a lack of it. 



934 DISEASES. 

Again, I can see nothing in the clinical history or pathology of 
this disease which in any way justifies us in disordering metabolism 
by the institution of a rigid milk diet. 

It is my custom to give all patients, after the first week of typhoid, 
from one to two soft-boiled eggs a day in addition to the ordinary 
allowance of milk, and to \ary their diet by the use of curds and whey, 
rice which has been boiled to a pulp, barley, and wheat gruel, and a cup 
of corn starch with vanilla or some other flavoring substance of a like 
character. As a result I very rarely see the marked ataxia which is so 
common a symptom in convalescence from typhoid fever. The patient's 
nutrition is so well preserved that he is but little more emaciated than 
many cases of acute pneumonia at the time of recovery. Secondary 
complications like furuncles and bed-sores are almost unknown, for 
by the use of a plentiful supply of food the patient's vital resistance is 
maintained to such a degree that simultaneous collateral infections 
do not take place. The average case of convalescent typhoid fever is 
a fair mark for any infection because it is half-starved. 

When starches are used, it is the author's invariable rule to give 
taka-diastase, in the dose of 5 grains with each meal. 

Recognizing that typhoid fever is characterized by a deficient 
secretion of digestive juices, all these patients receive hydrochloric 
acid and pepsin when proteids are administered, and taka-diastase 
and pancreatin when carbohydrates are used. 

In some instances, milk agrees with the patient if it i .; partly diluted 
with plain soda-water, Vichy or Apollinaris water. 

For the dry and sordes-covered tongue a mouth-wash of glycerin 
and water, half and half, to which may be added a little lemon-juice, 
is used, and it is important to keep the mouth constantly cleansed, as 
by this means swallowing is not interfered with through cracking of 
the lips, tongue, and buccal mucous membrane, pulmonary infection 
is avoided, and facial erysipelas and parotitis are prevented. 

If constipation is very obstinate and continues over one day, an 
injection is employed, and if this, after being used twice, fails to act, 
a dose of calomel, J grain (0.001) every fifteen minutes until a grain 
has been taken, is prescribed, and, if no movement occurs in twelve 
hours, is followed by half a bottle of citrate of magnesium, or a tea- 
spoonful of liquorice powder is given. In other cases small doses of 
cascara sagrada are equally useful. Violent purgatives should never 
be used, for obvious reasons. Rectal injections should be given some 
hours after the purgative is taken, to aid its action, since not infre- 
quently the laxative causes the contents of the small intestine to flow 
into the large bowel, which is too inactive to extrude them. 

When diarrhoea becomes troublesome — that is, more than three or 
four passages a day — the following will be of service: 

1^ — Acidi sulphurici aromatici f oij (8.0). 

Fluidextracti hsematoxyli f 5iij (12.0). 

Syrupi zingiberis f §iij (90.0). — M, 

S. — Teaspoonful (4.0) in water every hour until relieved. 



TYPHOID FEVER. 935 

Should the stools be excessively fetid and tympanites be marked, 
guaiacol carbonate or phenolsulphonate of sodium may be given as an 
intestinal antiseptic, or, as soon as any evidence of tympanites 01 
much meteorism comes on, turpentine may be given, as follows: 

^— Olei terebinthinse foij (8.0). 

Syrupi acaciee q. s. ad f oiij (90.0). — M. 

Fiat emulsum 

S. — Teaspoonful (4.0) in milk three times a day. 

At the same time it is well to employ a turpentine stupe over the abdo- 
men. (See Turpentine.) Where the tympanites is excessive it may 
be relieved by an injection made as follows: 

1^— Olei terebinthinse f 5j to 5ij (4.0-8.0). 

Oleiolivae f§iv (120.0). 

Emulsi asafcetidae Oj (480 mils.).— M. 

S. — Use as an injection. Shake well before using. 

When the tympanites is severe, half an ounce (16.0) of Hoffmann's 
anodyne may be used in place of the turpentine. 

In the later stages of typhoid fever, as convalescence is approached, 
turpentine is often useful, as it seems to cause rapid healing of the 
intestinal ulcers and checks diarrhoea. 

Much has been said about the value of purgatives and so-called 
intestinal antiseptics in typhoid fever, and extravagant claims made 
for them. Suffice it to state that while they may be indicated in cer- 
tain cases they are not to be used as a routine plan of treatment, because 
the skill of the true physician is to give each patient what he needs — 
not to give all the same treatment. Typhoid fever cannot be aborted; 
it can only be modified in the sense that we place our patients in the 
best possible physical state to withstand its ravages. 

A point of importance in the treatment of typhoid fever is to see 
that the patient receives enough water in twenty-four hours. Owing 
to his apathy he often does not complain of thirst and the kidneys are 
not flushed of impurities by fluid. Some perfectly pure water, such as 
Londonderry Lithia, or Poland water, should be freely given to help 
eliminate toxic materials through the kidneys. Should toxaemia be 
severe, the use of cold is essential, and if in addition emaciation be 
marked, it is wise to employ hypodermoclysis. (See Part III.) 

Not infrequently cases are met with in which toxaemia with mental 
depression is well developed, yet in which the temperature is below 
102° F., and so the use of cold sponging seems contraindicated. Active 
friction with tepid water and alcohol is now of value. If the tempera- 
ture is normal or subnormal, the patient may be sponged with hot 
water. The value of this measure does not lie so much in the tempera- 
ture of the water as in the reaction and consequent readjustment of 
the circulation. 

As during the later davs of the disease and in convalescence a large 
number of typhoid bacilli are in the urine, the routine use of urotropin 
or uritone, as a urinary antiseptic, is resorted to by many physicians. 



936 DISEASES. 

It may also be used to prevent cholecystitis arising from this infection 
and to prevent the spread of the disease by the dejections of so-called 
"typhoid carriers." (See Hexamethylenamine.) 

The complications of typhoid fever of the most serious import are 
hemorrhage from the bowel, pneumonia and pleurisy, and perforation 
of the bowel. 

The hemorrhage from the bowel may be treated as indicated under 
that heading (see Hemorrhage), and the pneumonia or pleurisy should 
be treated as are these diseases when they occur alone; but it is to be 
remembered that the patient is an asthenic adynamic case, and must 
not be depressed and may need stimulation. 

When perforation of the intestine occurs, only enough morphine 
should be given to relieve agony. Warm applications should be 
used over the belly and down the limbs, and stimulants given if 
needed. In all cases where it is possible to find a surgeon capable 
of doing a skilful abdominal section, a consultation should be had 
at once. As a rule, the operation should be performed immediately. 1 
(See Shock.) 

As stated at the beginning of this article, cold bathing is very im- 
portant and should always be employed in one of its forms if the 
fever is high, except in the presence of pneumonia, hemorrhage, or 
perforation, provided the patient reacts. 

For a number of days after the patient begs for solid food it should 
not be allowed, for he will ask for it long before he should have it; 
but if the temperature remains normal after nine days, solid food may 
be used and the patient gradually brought back to an ordinary sim- 
ple diet. 

UREMIA. 

The treatment of this dangerous manifestation of renal disease is 
often futile, but always to be resorted to with the recollection that 
wonderful recoveries sometimes occur under judicious management. 
It matters little whether the onset of the symptoms has been gradual 
or instantaneous: in either event the prime endeavor must be to rid 
the system of the poison which is threatening life. This can only be 
accomplished by aiding its elimination through the bowels, skin, 
and kidneys. The second indication is to support the vital organs 
until the emunctories have had time to act. Often this second indi- 
cation will be more pressing than the first, and the physician will 
have to give stimulants at once. The third indication is to arrest any 
convulsive seizures. 

The methods to be resorted to for the elimination of the ursemic 
poison are external and internal, externally the hot pack being resorted 
to to increase the activity of the skin. (See Heat, Part III.) Inter- 
nally we give elaterium or elaterin in the dose of J grain (0.01) or yg 

1 For discussion of this condition see the author's work on the Medical Complications 
and Sequelae of Typhoid Fever. Lea & Febiger, Philadelphia, second edition, 1909. 



URAEMIA. 937 

grain (0.004), respectively, for the induction of watery purging, which 
at once aids elimination through the bowel and relieves dropsy if 
present. The elaterin should be dissolved in a few drops of alcohol 
or in whisky. The medication directed to increased action of the skin 
may consist of small doses, hypodermically — say i grain (0.008) — of 
hydrochloride of pilocarpine with strychnine £$ grain (0.003), but the 
pilocarpine is contraindicated unless the heart is strong and acting 
properly and if there is present the slightest tendency to pulmonary 
oedema. Even if the heart seems strong its use is not devoid of danger. 
It may be used in conjunction with the hot-pack or hot-air bath. As 
a rule it is better to bleed, if there is venous congestion, and follow this, 
if need be, by hypodermoclysis. 

In every case of ursemia the blood-pressure should be taken and an 
estimate made of the strength of the heart muscle by a study of its first 
sound and the vigor of the pulse. If the blood-pressure is much above 
normal, say 150 or 160 millimeters of mercury, stimulants are not 
needed, as a rule, but nitroglycerin aV grain (0.001) or sodium nitrite 
1 to 2 grains (0.06-0.12) may be given. Aromatic spirits of ammonia 
and Hoffman's Anodyne are valuable if the heart is weak, and are to 
be followed by strychnine and digitalis if necessary. 

For the support of the heart and respiratory function we employ 
strychnine hypodermically or by the mouth in the dose of 3 \j to T V 
grain (0.003-0.006), and follow it by the more powerful stimulant 
digitalis in the dose of 30 minims (2.0) of the tincture by the mouth. 
Hypodermic injections of ether are also very valuable if the tissues 
are not too cedematous for absorption to occur. 

Should pulmonary oedema threaten, atropine may be given in full 
dose with advantage and dry cups should be placed over the bases of 
both lungs. 

The convulsions, if present or threatened, are to be combated by 
the use, after the bowels have been washed out, of an enema of 20 
grains of chloral (1.3) and 60 grains (4.0) of bromide of sodium in 3 
ounces (90.0) of starch-water, and the hot pack will also be of value, not 
only to produce sweating, but for its sedative influence on the nervous 
system. Should the convulsive tendencies be marked, amyl nitrite inha- 
lations may be employed until the chloral and bromide can be absorbed. 

Two other remedial measures should be resorted to in case of 
uraemia for the relief of all symptoms — namely, full venesection if 
the pulse is bounding, and hypodermoclysis. (See Part III.) Vene- 
section is contraindicated in the feeble, but as much as 1 to 2 pints 
(480-960) cf blood may be withdrawn in a sthenic case from a vein in 
the arm. A fter the bloodletting or during its progress hypodermoclysis 
may be performed or a saline solution transferred into a vein. (See 
Transfusion. ) Often deep insensibility is speedily removed by vene- 
section whicl should be regarded as the sheet-anchor of treatment in 
those cases wl ich have a high blood-pressure. The author also regards 
hypodermoclysis and intravenous transfusion of salt-solution as most 
useful methods of treatment in this state. 



938 DISEASES. 

VITREOUS DISEASES. 

Vitreous opacities may be either dust-like, flaky, or dense and 
membranous. They impair vision in proportion to their number and 
density, and are to be detected with the ophthalmoscope. Patients 
observe them as floating dark spots in their field of vision, because the 
opacities cast a shadow upon the retina. If vitreous disease is syphil- 
itic, the usual remedies are indicated. Hypodermic injections of 
pilocarpine or sweating by the electric cabinet act favorably. Gal- 
vanism has been recommended. Often opacities are due to uveitis, 
choroiditis, and chorio-retinitis, and these states must be treated 
according to their causation. 

VOMITING. 

Vomiting is a symptom, not a disease, and arises from a large 
number of causes, some of which are very unimportant, others very 
serious. The most common cause is probably imperfect digestion, 
with all that this implies; that is, gastro-intestinal irritation and per- 
version of normal function. Additional causes are cerebral hemor- 
rhage, tubercular meningitis, cerebritis, ursemia, or diseases of the 
middle lobe of the cerebellum, all of which conditions cause irritation 
of the vomiting centre. 1 In children it is occasionally due to a disorder 
of metabolism which results in a state characterized by acidosis as 
in so-called cyclic vomiting and in cholera infantum. 

Some of these states may be considered as lesions of a centric 
character which directly or indirectly cause the vomiting centre to send 
out impulses. On the other hand, it is worthy of note that under cer- 
tain circumstances vomiting may be reflex and dependent upon irrita- 
tion of the nerves of the stomach or elsewhere which convey impulses to 
the centre and the muscles whose activity results in vomiting. These 
conditions are well represented by the vomiting which comes on in 
incarcerated hernia, or in pregnancy, or in that occurring during the 
passage of renal or hepatic calculi, or in indigestion. 

It is important to bear in mind that peripheral vomiting due to dis- 
order of the gastric walls may be dependent upon two conditions. 
The mucous membrane and its nerves may be overexcitable or they 
may be depressed. For this reason we shall find that two modes of 
treatment are necessary when this subject is considered below. 

The mechanism of vomiting consists in the closure of the pyloric 
sphincter, the contraction of the gastric muscles from the pylorus to 
the cardia, and at the same time, and more important than these 
movements, the contraction of the supplementary respiratory and 
abdominal muscles, which so compress the stomach as to drive its 
contents through the open oesophagus. The violence of the muscular 

1 See Diagnosis in the Office and the Bedside, by the author. Lea & Febiger, Phila* 
delphia. 



VOMITING. 939 

contractions in the abdominal walls is greatest when the stomach is 
partly empty, and gives rise to the pain and exhaustion accompanying 
the condition known as retching. The practical point to be learned 
from this is that vomiting is always easier when the stomach is not 
empty; so if an emetic is given on an empty stomach, as the popular 
expression runs, a large amount of liquid should precede or accom- 
pany it if possible. Dogs vomit easily because of the development of 
their gastric muscles, but they render the effort easier by filling the 
stomach with air or grass, and so completely fill the viscus that its walls 
can contract on a resisting mass. 

Having described the mode and causes of vomiting, it remains to 
consider its treatment. 

It is needless to remark that the vomiting of cerebral disease is 
very intractable, and that very active agents must be used to check it. 
The vomiting following etherization is often centric, and should be 
treated, as should all forms of obstinate emesis, by the injection into 
the rectum of 40 grains (2.4) of sodium or potassium bromide and 20 
minims (1.2) of tincture deodorized opium in 4 to 8 ounces (120.0-240.0) 
of starch-water. If this does not check the vomiting, a second injection 
may be given two hours after the first. A very valuable remedy in this 
state is acetanilide given in 1-grain (0.06) doses every half-hour in a 
drachm of brandy with cracked ice (see Acetanilide), and it is well to 
remember that inhalation of the fumes of vinegar from a cloth wetted 
with it will often be of service. In other cases relief is obtained by 
washing out the stomach. 

When vomiting seems to be due to hyperexcitability of the gastric 
mucous membrane, so that very small amounts of food when swallowed 
are at once rejected, local anaesthetics and depressants are needed, the 
chief of these being chloretone, cocaine, and aconite. The last two 
drugs, however, have disadvantages, because in effective dose their 
general physiological action may be very severe and almost poison the 
patient. When given as anti-emetics, these drugs act as local anaes- 
thetics, or, in other words, by paralyzing the peripheral sensory nerves 
of the stomach. Cocaine should be given in the dose of 2 to 3 minims 
(0.1-0.20) of a 4 per cent, watery solution every fifteen minutes until 
10 minims (0.60) are taken. And it is best given in capsule so as to 
exert all its effects on the stomach rather than on the mouth and 
oesophagus. The aconite should be used in the form of the tincture, 
the patient being placed flat on the back, so as to withstand the ensuing 
cardiac depression with the least inconvenience, and 6 to 10 minims 
(0.40-0.60) of the tincture given in a little water every thirty minutes 
until the rapidly weakening pulse forbids its further use. This drug 
may be resorted to in all forms of vomiting due to irritability of the 
stomach, but it is contraindicated in cases of debility or weakness. 

Two grains of chloretone given in capsule or dissolved in a little 
brandy and poured over cracked ice and given in very small doses are 
useful. This treatment may be repeated every hour for 5 doses, and 
is very efficient. 



940 DISEASES. 

Sometimes a prescription of the following character is of service, 
the bismuth acting as a coating to the wails of the stomach, protecting 
and soothing them: 

1^ — Bismuthi subnitratis 3iij (12.0). 

Fluidextracti aconiti rruij velvj (0.20-0.40). — M 

Fiant chartulas No. x. 

S. — One powder every half-hour. 

In other cases of the same type the following is useful, and is to be 
preferred if, owing to active fermentation, the vomiting is excessive 
(the creosote or phenol being a local anaesthetic and antiseptic) : 

1$ — Phenolis vel creosoti (beechwood) . . . gtt. x vel xx (0.60-1.3). 

Bismuthi subnitratis 3iij (12.0). — M. 

Fiant chartulas No. x. 

S. — One powder every hour. 

In other cases 1 drop of tincture of iodine and 1 drop of phenol in a 
couple of drachms of water will act very well. 

Sometimes pure chloroform in 1- or 2-drop (0.06-0.1) doses, in a 
little water, does good; and dilute hydrocyanic acid, in the dose of 2 
to 5 minims (0.1-0.3) is also of value in like instances, given in a 
tablespoonful (15.0) of water. 

In other instances small repeated doses of nitroglycerin do good. 
Particularly is nitroglycerin useful in the nausea which often follows 
the use of opium, although this symptom is best prevented by its pre- 
liminary use. The dose used should be about -gfo grain (0.0002) every 
half-hour. 

The treatment of a case of vomiting dependent rather upon depres- 
sion and debility of the stomach than upon irritation is directed to the 
administration of gastric and, it may be, systemic stimulants. The 
chief of the gastric stimulants is ipecac in small doses, and it is this 
employment of a drug generally resorted to for the production of 
emesis by physicians which has caused homoeopaths to claim that the 
regular school obey the rule of similia similibus curantur and infinitesi- 
mal dose. The claim only holds good on its face, for we do not use 
an infinitesimal dose, and obey no law, but use common sense. Ipecac 
is an irritant, even to the skin, and it is partly by its irritant effects 
in large doses that it causes vomiting by exciting the stomach to a point 
over and above its normal condition. In the vomiting depending upon 
gastric debility and depression small doses of ipecac do good because 
they irritate the stomach sufficiently to restore its normal tone without 
going to the other extreme of hyperexcitation. Under these circum- 
stances a drop dose of the wine of ipecac, or \ grain (0.015) of the 
powdered ipecac, every hour, is of the greatest value, often succeeding 
after all other remedies have failed. 

In other instances tincture of nux vomica, given in \- to l-min?m 
(0.03-0.06) doses, is useful as follows: 

1^ — Tincturae nucis vomicae .... gtt. iv vel viij (0.25 0.5). 
Aquas cinnamomi f §j (30.0). — M. 

S. — Teaspoonful (4.0) every half -hour or later. 



VOMITING. 941 

In the nausea and vomiting following an alcoholic debauch J to 1 
minim (0.03-0.06) of Fowler's solution every two hours, or before 
food, often gives relief, and it may be used in some cases in place of 
the nux vomica and ipecac. Another useful measure for the cure of 
alcoholic nausea if the tongue is heavily coated is the use of full doses 
of hydrochloric acid, 5, 10, or 15 minims (0.3-0.60-1.0) of the dilute 
acid in half a tumblerful of water, repeated every two hours. 

In all cases of persistent vomiting counterirritation should be applied 
over the stomach in the form of a mustard plaster, or, if preferred, an 
ice-bag may be applied to the nape of the neck, the lumbar spine, or 
the epigastrium. Sometimes the application of the positive electrode 
of the rapidly interrupted induced or faradic current between the 
sternoclavicular muscles while the negative electrode is placed on 
the epigastrium will give relief. In still other cases the skin over the 
vagus nerves in the neck may be frozen by the use of a chloride of 
ethyl spray, or blisters may be applied in its stead. 

The food given in cases of vomiting should be especially prepared. 
It is always best to use peptonized milk, made by using the pepton- 
izing materials sold by several reliable drug firms. (See Diet, Part III.) 
Lime-water should always be put in the milk if it is not peptonized; 
the small amount usually employed is perfectly useless, at least 2 to 
3 tablespoonfuls (30.0-45.0) should be placed in each glass of milk. 

Another point of importance is the quantity of liquid taken. As 
fast as the patient vomits he is often fed with glasses full of liquid 
by well-meaning friends. Instead of this, he should have only 1 or 2 
teaspoonfuls (4.0-8.0) of milk every hour, half-hour, or fifteen min- 
utes, for it is better for him to retain a drachm than to take a quart 
and vomit it. Often milk will disagree with the patient, and then he 
may be given with excellent result barley gruel, which has been strained, 
and follow it by 3 grains (0,20) of taka-diastase or a drachm (4.0) of 
liquid taka-diastase. In its place strained gruel made from wheaten 
grits, oatmeal, or rice may also be used. 

When the vomiting of pregnancy becomes pernicious in type the only 
cure is emptying of the uterus. Moderate types can be benefited 
sometimes by sodium bicarbonate or levulose (see above). In the 
cyclic or toxaemic vomiting of childhood, eggs are to be forbidden and 
levulose in solution given by the rectum by the drop method, as this 
state is akin to diabetic coma. (See Diabetes.) So, too, it not 
infrequently happens in the severe diarrhoeas of early childhood that 
the body turns upon its fats for energy and oxybutyric acid is produced 
causing so-called acidosis. Usually the child will have hurried respi- 
rations and a tendency to stupor. Under these conditions bicarbonate 
of sodium should be given freely in solution by the mouth and by the 
Murphy drip. As much as an ounce of the soda in twenty-four hours 
being used in the strength of 2 drachms to 8 ounces (8.0: 350) of water, 
if possible. Levulose may also be used by the rectum, by the drip 
method, the strength of the solution being 15 Gm. to 1000. A few 



942 DISEASES 

ounces of this solution going at the rate of 10 drops to the minute may 
be given every eight hours. When the condition is urgent, sodium 
bicarbonate solution should be given intravenously in the strength 
of 4 per cent, or by hypodermoclysis in the proportion of 2 per cent, 
and continued until the urine is reduced alkaline. If bicarbonate 
of sodium is used by hypodermoclysis the solution must not be boiled, 
as it will be changed into the irritating sodium carbonate and cause 
a slough. In children as young as twelve months as much of the 
bicarbonate may be used as 2 drachms (8.0) in twenty-four hours. 

WHOOPING-COUGH. 

The remedies recommended for this disease are almost as numerous 
as the members of the medical profession, and every one of them is 
worthless so far as a cure is concerned. Probably the very best drug 
of all in the majority of cases is antipyrine. Given in the dose of \ to 
3 grains (0.03-0.20) every five hours according to the age of the child 
it will nearly always decrease the number of paroxysms, but not the 
severity of each individual attack. (See Vaccine Therapy.) 

Where the child will submit to it there is little doubt that a solution 
of quinine applied to the pharynx by means of a very fine spray will be 
of service in many cases, and it is very useful when so used, as a pro- 
phylactic in other children of the family who it is feared will be attacked 
by the same disease. The strength of the solution to be employed 
should be about 1 grain (0.06) to the ounce of water. 

There is no doubt that carburetted hydrogen as inhaled in the air at 
gas-works is useful as a curative measure in some cases of whooping- 
cough. 

A very useful remedy in some cases is belladonna in the form of the 
tincture, in the dose of 2 minims (0.12) twice a day to a child of one or 
two years. 

Where paroxysms come on so rapidly as to interfere seriously with 
respiration, the child should inhale a whiff of chloroform, the drug 
being poured over the parent's hand, and so relax the spasm, while in 
other instances nitrite of amyl is equally serviceable. Only 2 or 3 
minims of the nitrite of amyl should be used at a time, and this fact 
must be impressed upon the parents. 

Benzine has been found useful in certain cases of whooping-cough. 
It should be lightly sprinkled about the room or on the bed-clothing, 
care being taken that no fire or light is present. In France it has been 
used internally in the dose of 10 to 15 minims (0.6-1.0) for this affection. 
This is scarcely to be recommended. 

Bromoform renders good service in some cases. (See article on 
Bromoform for prescription.) 

The vomiting following the cough may be overcome by using such 
minute amounts of milk as to enable nutrition to go on without at any 
time overloading the stomach, as, for example, a teaspoonful (4.0) 
after each paroxysm of cough. 



WORMS. 943 

Usually it will be found advisable to modify the severity and fre- 
quency of the attacks by keeping the patient under a bronchitis-tent or 
by keeping the air of the room moistened by steam. (See Bronchitis.) 

WORMS. 

Intestinal parasites may be said to be represented by Ascaris lum- 
bricoides or round-worm; Taenia mediocanellata, Taenia solium, Taenia 
saginata, and Bothriocephalus latus, or tape-worm; and, finally, by 
Oxyuris vermicularis, sometimes called seat-, pin-, or thread-worm. 
Another intestinal parasite, one which is quite frequently found in some 
parts of the old world, is Anchylostoma duodenale, or in this country 
the Uncinaria Americana (Necator Americanus or Hook-worm.). 

The round-worm, tape-worm, and hook-worm are to be attacked 
by way of the patient's mouth, the seat-worm by way of the anal open- 
ing; but before mentioning the drugs to be employed it is necessary 
to insist upon one or two important points, disregard of which will result 
in failure in treatment. 

Whenever a round-, hook-, or tape-worm is to be attacked, the patient 
must be starved for at least twelve to twenty-four hours, in order that 
no food in the intestinal tract may protect the worm from the action 
of the drug. During this time a little milk may be taken, and after 
a night of fasting, before breakfast, the anthelmintic must be swal- 
lowed. In addition, nearly all of these drugs must be followed by 
purges in order to dislodge the intruder while he is paralyzed and 
has lost his hold; and in many instances it is well to have a basin of 
salt and water ready, so that when a passage occurs a rectal injection 
may be given to wash out the worm in the rectum. . 

In the treatment of thread-worms it is necessary to fill the bowel 
thoroughly with soap and water to dislodge the fecal matter and 
expose the worms in the folds of the mucous membrane. 

The drugs which are used against the round-worm are : spigelia in 
the form of the- fluidextract, dose 1 drachm (4.0) to a child of two 
or three years, or 2 drachms (8.0) to an adult, or, better still, the fluid- 
extract of spigelia and senna, dose 2 to 3 drachms (8.0-12.0) given 
in divided doses, to a child; santonin, dose i to ^ grain (0.015-0.03) 
to a child in the form of a troche, made by using the crystals, or as 
much as 2 to 4 grains (0.12-0.25) to an adult. (See Santonin.) 

Unless the spigelia is used with senna, it should always be followed 
after from two to four hours by a full dose of castor oil or a saline 
purgative to sweep out the worm, and the same rule applies to all the 
drugs mentioned above. 

Brayera, or kooso, is given for the removal of the tape-worm in the 
form of an infusion, which is made by adding \ ounce (16.0) of the 
powdered leaves to 1 pint (480 mils.) of water and mucilage of acacia, 
one-half of each. This may be taken at one dose, or the fluidextract 
may be given in the dose of \ ounce (15.0) to an adult. Koosin may 



944 DISEASES. 

be given in 40- grain (2.6) doses in capsule to adults, but it should not 
be used against worms in pregnant women, as it may cause abortion. 

The most efficient remedy against the tape-worm is pelletierine, the 
active principle of pomegranate, dose 3 to 5 grains (0.20-0.30) in 
capsule; or pepo, or pumpkin-seeds (2 ounces [60.0]), may be resorted 
to when deprived of their outer coating and rubbed into a paste with 
sugar. Almost, if not quite, as valuable a remedy is male fern, or 
Filix mas, or, as it is officially called, Aspidium. Used in the form 
of the oleoresin (Oleoresina Aspidii), in the dose of J to 1 drachm 
(2.0-4.0) to an adult, it should be followed in three or fours by a 
calomel purge, aided by a saline. Either the calomel or the increased 
amount of bile which is present is apparently peculiarly abhorrent to 
the tape-worm, and its free flow should be made to follow the use of 
all the drugs just named. Aspidium should not be followed by castor 
or other oils, as they increase the absorbability of the drug, and so 
tend to develop symptoms of poisoning. 

For the removal of Uncinaria, thymol in the dose of 2 to 4 grains 
(0.12-0.25) or more may be given in capsule once a day and followed 
by a purge. (See Thymol and Chenopodium.) 

By far the most useful remedy for seat-worms is quassia used by 
injection. One to 2 ounces (30.0-60.0) of powdered quassia or quassia 
chips may be made into a decoction with a pint (480 mils.) of water, 
and half of this injected into the rectum after it has been well cleansed 
with soap and water. The quassia injection should be retained in 
the bowel for some minutes, and in children this may be aided by 
pressing upon the anal opening the ball of the thumb covered by a 
pad formed from a small folded towel. If this treatment fails to 
bring away the worms in three or four trials, either there are none 
present or the bowel was not thoroughly invaded by the injection. In 
some cases the worms infest the colon, and large injections sent high 
up into the bowel are necessary. 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Abbreviations, 61 
Abies excelsa, 446 
Abortifacients, 49 
Abrin, 340 

Abrus precatorius, 340 
Absolute acetic acid, 70 

alcohol, 75, 82 
Absorption of drugs, 44 
Abstracts, 34 
Acacia, 63 

incompatibles of, 63 

mucilage of, 63 

syrup of, 63 
Acaciae gummi, 63 
A. C. E. mixture, 207, 274 

Billroth's, 207 
Aceta, 34 
Acetanilid, 63 

poisoning by, 66 
Acetanilidum, 63 
Acetate of aluminum, 88 

of ammonium, 92 

of lead, 348 

of potassium, 450 

of sodium, 483 

of zinc, 531 
Acetic acid, 68 

Acetphenetidin (phenacetin), 69 
Acet-theocin-sodium, 509 
Acetum, 68 

cantharidini, '34 

ipecacuanha?, 331 

lobeliae, 354 

opii, 416 

sanguinarise, 472 

scillse, 34, 489 

urginea, 34 
Acetyl-salicylic acid, 134 
Acid, acetic, 68 

acetyl-salicylic, 134 

arsenous, 113, 120 

benzoic, 145 

boric, 149, 150, 544 

camphoric, 174 

carbolic, 428 

cathartic, 478 

chromic, 212 

chrysophanic, 460 

cinnamic, 224 

citric, 225 
60 



Acid, cubebic, 249 
ecbolic, 262 
ergotic, 262 
ergotinic, 262 
gallic, 288 
gentisic, 292 
hydriodic, dilute, 306 
hydrobromic, 158 
hydrochloric, 306 
hydrochloride of quinine, 221 
hydrocyanic, 307 
infusion of cinchona, 224 

of roses, 462 
ipecacuanhic, 328 
kinic, 214 
kinotannic, 342 
kinoric, 214 
kolatannic, 342 
lactic, bacillus, 343 
lobelic, 354 
lupulinic, 304 
meconic, 406 

methylene-citryl-salicylic, 400 
nitrate of mercury, 376 
nitric, 390 

nitrohydrochloric, 307, 394 
phenic, 428 
phenyl-cinchonic, 135 
phosphoric, 434 
picric, 439 
polygalic, 478 
prussic, 307 
pyrogallic, 457 
ricinoleic, 183 
salicylic, 463 
santoninic, 472 
sclerotinic, 262 
sodium phosphate, 485 
sphacelinic, 262 
sulphuric, 498 
tannic, 504 
tartaric, 507 

tartrate of potassium, 451 
trichloracetic, 515 
valerianic, 526 
Acidum aceticum, 68 

diliitum, 68 

glaciale, 68 
acetylsalicylicum, 134 
arseniosum, 113, 120 
benzoicum, 145, 146 
boricum, 149, 150 

(945) 



946 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Acidum camphoricum, 174 

carbolicum, 428 

liquefactum, 433 

chromicum, 212 

citricum, 225 

gallicum, 288 

hydriodicum dilutum, 306 

hydrobromicum dilutum, 158 

hydrochloricum, 306 
dilutum, 307 

hydrocyanicum, 307 
dilutum, 307 

nitricum, 390 
dilutum, 391 
fumans, 391 

nitrohydrochloricum, 307, 394 
dilutum, 307, 394 

phenyl cinchonicum, 135, 400 

phosphoncum concentratum, 434 
dilutum, 434 

picricum, 439 

salicylicum, 463 

sulphuricum, 498 

aromaticum, 499 
dilutum, 499 

tannicum, 504 

tartaricum, 507 

trichloraceticum, 515 

valerianicum, 526 
Acoine, 70 
Aconine, 71 
Aconite, 70 

liniment, 74 

poisoning by, 72 
Aconitina, 74 
Aconitine, 70, 74 

Duquesnel's crystalline, 73 

ointment, 74 

olcate, 73 
Aconitum Napellus, 70 
Action of drugs, direct, 29 
duration of, 45 
indirect, 29 
modes of, 20 
Acupuncture, 535 
Adalin, 74 
Adeps benzoatus, 145 

benzoinatus, 145 

lanse, 344 

hydrosus, 344 
Administering drugs, modes of, 29 
Adonidin, 74 
Adonis vernalis, 74 
Adrenalin, 499 
Adrenalinum, 499 
^Ether, 265 

fortior, 266 

purificatus, 265 
iEthylcarbonate of quinine, 284 
iEthylis bromidum, 276 

chloridum, 277 

iodidum, 280 

salicylas, 469 
^Ethylmorphinse hydrochloridum, 260 
Agar, 75 



Agaric, 75 
Agaricin, 75 
Alcohol, 75, 82 

absolutum, 75, 82 

administration of, 81 

amylic, 75 

contraindications to, 82 

dehydratum, 75, 82 

dilutum, 75, 82 

ethylicum, 75 

phenylic, 428 
Alcoholism, acute, 79 

differentiation of, from apo- 
plexy, 80 
from opium-poisoning, 80 

chronic, 80 

from paretic dementia, 81 
i Aldehyde, formic, 286 
Ale, 83 
Alkaloids, 34 
Allis ether inhaler, 272 
Allium, 83 

-juice, 83 

sativum, 83 

syrup of, 83 
Allspice, 444 
Almond bread, 84, 650 

milk, 650 
Almonds, 83 

bitter, 83 

sweet, 84 
Aloe, 84 

Chinensis, 84 

Perry i, 84 

vera, 84 
Aloes, 84 

compound decoction of, 86 

contraindications to, 86 

glycerole of, 86 
Aloin, 85, 86 
Aloinum, 85, 86 
Alpha-eucaine, 281 
Alteratives, 49, 53 
Alum, 87 

acetate solution, 88 
Alumen, 87 

exsiccatum, 88 

purificatum, 87 
Alumini acetas, 88 
Aluminum acetate, 88 
Alypin, 88 
Amber, 89 

American wormseed, 186 
Ammonia, 89 

liniment, 91 

-water, 91 

stronger, 91 
Ammoniac, 91 
Ammoniacum, 91 
Ammoniated glycyrrhizin, 352 

liniment of camphor, 173 

mercury, 368 

tincture of ergot, 265 
of guaiac, 297 
of opium, 416 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



947 



Ammoniated tincture of quinine, 221 

of valerian, 527 
Ammonii acetas, 92 

benzoas, 92 

bromidum, 92 

carbonas, 93 

chloridum, 94 

iodidum, 95 

phosphas, 96 

valeras, 96, 527 
Ammonio-ferric alum, 333 
Ammonium, 92 

ichthyol, 314 

sulphate, 96 
Amygdala dulcis, 83 
Amygdalin, 83, 456 
Amyl nitrite, 96 
Amylic alcohol, 75 
Amylis nitris, 96 
Amylopsin, 421 
Amylum, 490 
Anaesthesia by infiltration, 229, 230 

by rectal injection of ether, 275 

insufflation, 273 

nitrous oxide and oxygen, 397 

scopolamine-morphine, 477 
Anaesthetics, 49, 53 
Anaphrodisiacs, 49 
Anaphylaxis, 746 
Antacids, 49, 53 
Anthelmintics, 49. 53 
Anthrarobin, 98 
Antiarthritics, 49 
Antidiphtheritic globulin, 547 

serum, 546 
Antidotum arsenici, 123, 336, 356 
Antidysenteric serum, 548 
Antimalarials, 53 
Antifebrin, 64 
Antigonococcic serum, 548 
Antihydrotics, 49 
Antimeningitis serum, 548 
Antimonial powder, 99, 102 
Antimonii et potassii tartras, 99, 102 

oxidum, 99 

sulphidum, 99 

purificatum, 99 
Antimonium nigrum purificatum, 99 

sulphuratum, 99 

tartaratum, 99 
Antimony, 99 

compound pill of, 102 

ointment of, 102 
Antiperiodics, 49, 53 
Antiphlogistics, 49 
Antipneumococcic serum, 549 
Antip3 r retics, 54 
Antipyrina, 104 
Antipyrine, 104 
Antiseptics, 53, 536 
Antispasmodics, 54 
Antistreptococcus serum, 551 
Antitetanic serum, 550 
Antithyroidin, 515 
Antitoxin, 545 



Antitoxin for diphtheria, 546 

for dysentery, 548 

for gonorrhoea, 548 

for meningitis, 548 

for pneumonia, 549 

for streptococcic infections, 551 

for tetanus, 550 
Aphrodisiacs, 49 
Apiol, 109 
Apis mellifica, 303 
Apocynum, 110 

androsaemifolium, 110 

cannabinum, 110 
Apomorphinae hydrochloridum, 112 
Apomorphine, 110 
Apothecaries' measure, 36 

weight, 36 
Apothesine, 112 

Apparatus for intravenous salvarsan 
injections, 130 

nitrous oxide-oxygen-ether, 398 
Aqua ammoniae, 91 
fortior, 91 

amygdalae amarae, 84 

camphorse, 173 

chloroformi, 207, 212 

cinnamomi, 224 

creosoti, 248 

hamamelidis, 300 

menthae piperitae, 424 

pimentae, 444 

rosae, 462 
Aquae, 34 
Arbutin, 526 

Arctostaphylos uva ursi, 526 
Argenti nitras, 387 
fusus, 387 
mitigatus, 390 
Argyria, 388 
Argyrol, 112 
Aristol, 512 
Aristolochia reticulata, 490 

serpentaria, 490 
Aristolochin, 490 
Arnica, 113 

montana, 113 
Aromatic chalk powder, 165 

fluidextract, 224 

of cascara sagrada, 183 

mixture of iron, 333 

powder, 182, 224 

spirit of ammonia, 91 

sulphuric acid, 499 

syrup of cascara, 183 
of rhubarb, 461 

tincture of rhubarb, 461 
Arsenate of iron, 333 

of sodium, 113, 121 
exsiccated, 121 
Arseni iodidum, 120 

trioxidum, 113, 120 
Arsenic, 113 

trioxide, 113, 120 
Arsenous acid, 113, 120 
Arsenum, 113 



948 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Arsphenamine, 125 

contraindications to, 132 
provocative dose of, 127 
untoward effects to, 131 

Artemesia pauciflora, 472 

Artificial milk, 651 

Asafetida, 133 

Asafcetida, 133 

Asagraea officinalis, 527 

Aspidium, 133 
nlix-mas, 133 

Aspirin, 134 

Astringents, 49, 54 
mineral, 54 
vegetable, 54 

Atomization, 33 

Atophan, 135, 400 

Atoxyl, 135 

Atropa belladonna, 137 

Atropina, 138 

Atropinae sulphas, 137, 143 

Atropine, 137 

Auranine, 380 

Auri et sodii chloridum, 295 

Avoirdupois weight, 36 

Azedarach, 136 

decoction of, 136 
fluidextract of, 136 



B 



Bacillen emulsion tuberculin, 
Bacillus bulgaricus, 344 

lactic acid, 343 
Balsam of copaiba, 242 

of Peru, 136 
Balsamum Peruvianum, 136 
Barbital, 137 

sodium, 137 
Barbitonum, 137 
Barley-water, 649 
Barosma betulina, 159 
Basham's mixture, 332, 333 
Bath, Brand, 567 

cabinet, electric, 590 

cold, 560 

Russian, 587, 591 

stretcher, 567 

Turkish, 587 
Bearberry, 526 
Beechwood creosote, 245 
Beef essence, 648 

peptonized, 644 

-tea, 648 
Beer, 83 
Belladonna, 137 

contraindications to, 144 

leaves, 137 

liniment, 143 

ointment, 144 

plaster, 144 

poisoning by, 140 

root, 137 

suppositories, 144 



519 



Belladonnse folia, 137 

radix, 137 
Benzaconine, 71 
Benzamine lactate, 281 
Benzoate of ammonium, 92 
Benzoated lard, 145 
Benzoic acid, 144 
Benzoin, 144 
Benzoinated lard, 145 
Benzoinum, 144 
Benzonaphthol, 146 
Benzosulphanidum (saccharin), 463 
Benzoyl monohydro chloride, 88 
Berberine, 167, 305 
Beta-eucaine hydrochloride, 280 
Beta-eucainse hydrochloridum, 280 
Beta-naphthol, 145 
Beta-naphthol-bismuth, 145 
Bicarbonate of potassium, 451 

of sodium, 483 
Bichloride of mercury, 368 

as an antiseptic, 536 
Bier's hypersemic treatment, 552 
BiUroth's A. C. E. mixture, 207 
Bimuriate of quinine and urea, 222 
Biniodide of mercury, 371 
Binoxide of manganese, 359 
Bismuth, 146 

and ammonium citrate, 148 

betanaphtol, 145 

carbonate, 146 

hydroxide, 148 

milk of, 148 

salicylate, 148 

subcarbonate, 146 

subgallate, 146 

subnitrate, 146 

subsalicylate, 148 
Bismuthi betanaphtholas, 145 

carbonas, 146 

et ammonii citras, 148 

salicylas, 148 

subcarbonas, 146 

subgallas, 146 

subnitras, 146 

subsalicylas, 148 
Bisulphate of quinine, 221 
Bitartrate of potassium, 451 
Bitter almonds, 83 

wine of iron, 339 
Bitters, 50 
Black cohosh, 213 

draught, 476 

drop, 416 

ginger, 292 

mustard, 383 

oxide of manganese, 359 

pepper, 423 

snake-root, 213 

wash, 371 
Blaud's pill, 334 
Bleeding, 637 

Blistering collodion, 178, 239 
Blisters, 574 

figures showing areas to apply , 574, 576 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



949 



Blisters, flying, 575 
Blood-root, 472 
Blue-gum tree, 281 

-mass, 372 

ointment, 375 

pill, 372 
Bone-marrow, 293 
Boneset, 283 
Bonjean's ergotin, 265 
Borate of sodium. 149 
Bo rated lint, 150 
Borax, 149 

purificatum, 149 
Boric acid, 149, 150, 544 
Boroglycerin, glycerite of, 295 
Bouillon nitrate tuberculin, 519 
Bran bread, 650 
Brand bath, 567 
Brandy, 82 
Brassica nigra, 383 
Brayera, 250 
Bread, almond, for diabetics, 650 

bran, for diabetes, 650 
Bromdiethylacetylcarbamide, 74 
Brometone, 150 
Bromide of ammonium, 92 

of calcium, 156, 164 

of ethyl, 276 

of gold, 157 

of iron, 334 

of lithium, 157, 353 

of nickel, 157 

of potassium, 151 

of sodium, 157 

of strontium, 492 
Bromides, 151 

contraindications to, 156 

poisoning by, 155 
Bromine, 158 
Bromism, 155 
Bromoform, 158 
Bromoformum, 158 
Bromum, 158 
Bronchitis, moist air inhalations in, 33 

tents, 594, 602 
Broom, 475 
Brown mixture, 352 
Brucine, 401 
Bryonia, 159 

alba, 159 

dioica, 159 
Bryony, 159 
Buchu, 159 

folia, 160 
Bulgarian lactic acid bacillus, 344 
Burgundy pitch, 446 
Buttermilk and starch, 642 
Butyl chloral hydras, 248 



Cacodylate of iron, 334 

of sodium, 483 
Cactus grandiflorus, 160 



Cactus grandiflorus, fluidextract of, 161 

tincture of, 161 
CafTea, 161 

Arabica, 161 
Caffeina, 161, 163 

citrata, 161 

effervescens, 161 
Caffeinae citras, 161 

effervescens, 161 

sodio-benzoas, 163 
Caffeine, 161, 163. 334 

citrated, 163 
Cajuput oil, 164 
Calabar bean, 437 
Calabarine, 437 
Calamine, 531 
Calcii bromidum, 156, 164 

carbonas prsecipitatus, 164 

chloridum, 164, 165 

hydras, 171 

hypophosphis, 164, 166 

phosphas, 164 

praecipitatus, 164 

sulphidum crudum, 170 
Calcined magnesia, 356 
Calcium, 164 

bromide, 156, 164 

chloride, 164, 165 

glycerophosphate, 164 

hydroxide, 168 

hypochlorite, 170 

hypophosphite, 164, 166 

lactate, 164, 165 

lactophosphate, 164, 166 

oxide, 168 

phosphate, 164, 166 

sulphate, 167 
California buckthorn, 182 
Calomel, 372 

ointment, 374 
Calumba, 167 
Calumbae radix, 167 
Calumbic acid, 167 
Calumbine, 167 
Calx, 168 

chldrinata, 169 

sulphurata, 170 
Camphor, 171 

compound tincture of, 173 

liniment, 173 

mixture, Hope's, 304 

monobromate, 173 

spirit of, 173 

-water, 173 
Camphora, 171 

monobromata, 173 
Camphorated alcohol, 172 

oil, 172 

tincture of opium, 416 
Camphoric acid, 174 
Canada pitch, 446 

plaster, 446 
Cannabinol, 174 
Cannabis, 174 

indica, 174 



950 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Cannabis sativa, 174 
Cantharidal cerate, 178 

collodion, 178, 239 
Cantharidin, 177 
Cantharis, 177 

vesicatoria, 177 
Capsici fructus, 179 
Capsicine, 179 
Capsicum, 179 

fastigiatum, 179 

fruit, 179 

plaster, 180 
Carbo ligni, 181 
Carbolic acid, 428 

as an antiseptic, 537 
ointment, 433 
poisoning bv, 430 
Carbon, 181 

-dioxide snow, 555 
Carbonate of ammonium, 93 

of bismuth, 146 

of calcium, 164 

of creosote, 248 

of guaiacol, 298 

of iron, 332, 334 

of lead, 349 

of lithium, 353 

of magnesium, 355 

of potassium, 452 

of zinc, 531 
Cardamom, 182 

seed, 182 
Cardamomi semen, 182 
Cardiac sedatives, 50, 54 

stimulants, 50, 54 
Carminative powder, 224 
Carminatives, 50 
Carolina pink, 488 
Carron oil, 169, 286 
Caryophyllum, 225 
Caryophyllus, 225 
Cascara cordial, 183 

evacuant, 183 

sagrada, 182 
Casein milk, 642 
Cassia acutifolia, 478 

angustifolia, 478 

Carica papaya, 422 

fistula, 183 
Cassise pulpa, 183 
Castile soap, 481 
Castor oil, 183 
Cataphoresis, 29, 34 
Cataplasma carbonis, 181 

kaolini, 341 
Cataplasms, 34 
Cathartic acid, 478 
Cathartics, 50, 56 
Cat's-hair, 283 
Caustic potash, 454 

soda, 485 
Cautery, 575 
Cayenne pepper, 179 
Cephaelis ipecacuanha, 328 
Cerates, 34 



Cera turn cantharidis, 178 

plumbi subacetatis, 350 

resinse, 458 

compositum, 458 
Cerebral extracts, 293 
Cerii oxalas, 186 
Cerium oxalate, 186 
Chalk, 164 

mixture, 164 
Chamber inhaler, 601 
Champagne, extra dry, 82 
Charcoal, 181 

poultice, 181 
Charta potassii nitratis, 455 

sinapis, 384 
Chartae, 34 
Chenopodium, 186 

ambrosioides, 186 

oil of, 186 
Chinoidinum, 223 
Chloral, 186 

formamide, 191 

formamidum, 191 

hydras, 186 

hydrated, 186 

poisoning by, 188 
chronic, 188 
Chloramine, 191 
Chloralose, 192 
Chloralum hydratum, 186 
Chlorate of potassium, 452 

troches of, 453 
Chlorcosane, 542 
Chloretone, 192 
Chloride of ammonium, 94 

of calcium, 164, 165 

of ethyl, 277 

of gold and sodium, 295 

of iron, 332, 335 

of mercury, corrosive, 368 
mild, 372 

of methyl, 380 

of methylene. 381 

methylthionine. 382 

of sodium, 484 

of zinc, 532 

as an antiseptic, 544 
Chlorinated lime, 169 

as a disinfectant, 581 
Chlorine gas, 170 
Chlorobrom, 192 
Chlorodyne, 193 
Chloroform, 194 

contraindications to, 208 

inhaler, Esmarch's, 205 

Krohne and Seseman's modifi- 
cations of Lawrie's, 207 
Lawrie's, 206 

liniment, 212 

spirit of, 207, 212 

-water, 207, 212 
Chloroformum, 194 
Cholagogues, 50 

Chondodendron tomentosum, 423 
Chromic acid, 212 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



951 



Chromii trioxidi, 212 
Chromium trioxide, 212 
Chrysarobin, 213 

ointment, 213 
Chrysarobinum, 213 
Chrysophanic acid, 460 
Cimicifuga, 213 

racemosa, 213 
Cinchona, 214 

calisaya, 214 

ledgeriana, 214 

officinalis, 214 

rubra, 214 

rubra? cortex, 214 

succirubra, 214 
Cinchonicine, 214 
Cinchonidinoe sulphas, 223 
Cinchonidine, 214 

sulphate, 223 
Cinchoninse sulphas, 223 
Cinchonine, 214 

sulphate, 223 
Cinnamic acid, 221 
Cinnamomi cortex, 224 
Cinnamomum camphora, 171 

saigonicum, 224 

zeylanicum, 224 
Cinnamon, 224 

-water, 224 
Citrate, bismuth and ammonium, 148 

of iron, 335 

and ammonium, 335 
and quinine, 335 
and strychnine, 335 

of lithium, 353 

of magnesium, 356 

of potassium, 453 

of sodium, 484 
Citrated caffeine, 161 
Citric acid, 225 
Citrine ointment, 377 
Citrophen, 70 
Citrullus colocynthis, 239 
Clarified honey, 304 
Classification of drugs, 53 
Claviceps purpura, 262 
Climate, influence of, on dosage, 48 
Climates, 619 
Clove, 225 
Clyster, 32 
Coagulose, 556 

Cobalto-nitrite of potassium, 392 
Coca, 226 
Cocae folia, 226 
Cocaina, 226 

Cocainse hydrochloridum, 226, 231 
Cocaine, 226 

habit, 231 

hydrochloride, 226, 228 

oleate of, 228 
Cod-liver oil, 233 
Codeina, 232, 406 
Codeinse phosphas, 232 

sulphas, 232 
Codeine, 232, 406 



Codeine phosphate, 232 

sulphate, 232 
Coffee, 161 
Colchiceine, 236 
Colchici cormus, 236 
semen, 236 
semina. 236 
Colchicina, 236, 238 
Colchicine, 236, 238 
Colchicum, 236 

autumnale, 236 
corm, 236 
seed, 236 
Cold bath, 560 
cream, 462 
in fevers, 563 
as a remedy, 557 
Collodion, 238 

cantharidal, 178, 239 
flexible, 238 
iodol, 328 
styptic, 239, 505 
Collodium, 238 

cantharidatum, 178, 239 
flexile, 238 
stypticum, 239, 505 
vesicans, 178, 239 
Colocynth, 239 
Colocynthidis pulpa, 239 
Colocynthine, 239 
Colocynthis, 239 
Cologne-water. 82 
Columba, 167 
Columbine, 167 
Columbo, 167 

Combination of drugs for joint effect, 45 
Commercial oxide of zinc, 531 
Commiphora myrrha?, 384 
Compound cathartic pill, 239 
cerate of resin, 458 
decoction of aloes, 86 
effervescing powder, 478 
elixir of kola, 342 
extract of colocynth, 239, 474 
fluidextract of sarsaparilla, 474 
infusion of gentian, 292 
of senna, 359, 479 
liniment of mustard, 384 
mixture of iron, 334 
of liquorice, 352 
of senna, 479 
pill of antimony, 102 
of calomel, 374 
of colocynth, 240 
of galbanum, 133 
of rhubarb, 460 
of scammony, 475 
of soap, 416 
of squill, 489 
powder of almonds, 84 
of catechu. 290 
of chalk, 165 
of cinnamon, 224 
of elaterin, 262 
of ipecac ; 331, 416 



952 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Compound powder of jalap, 340 
of kino, 342 
of liquorice, 352, 479 
of morphine, 418 
of opium, 416 
of rhubarb, 460 
of scammony, 475 
solution of cresol, 355 

of iodine, 325 
spirit of ether, 301 

of juniper, 82, 341 
suppositories of lead, 349 
syrup of sarsaparilla, 474 

of squill, 102, 489 
tincture of benzoin, 145 
of camphor, 173, 416 
of cardamom, 182 
of chloroform and morphine, 

212, 418 
of cinchona, 224, 480 
of gambir, 289 
of gentian, 292 
of rhubarb, 461 
of senna, 479 
Condurango, 240 

bianco, 240 
Confectio piperis, 424 
rosse, 304, 462 

gallicse, 462 
sennae, 183, 479, 504 
sulphuris, 498 
Confections, 34 
Coniine, 240 

hydrobromide, 241 
Conium, 240 

maculatum, 240 
Conserves, 34 

Contraindications for drugs, 49 
Convallamarin , 242 
Convallaria, 241 
majalis, 241 
Convolvulin, 339 
Convolvulus scammonia. 474 
Cool sponging, 566 
Co-ordinated movements for treating 

locomotor ataxia and myelitis, 571 
Copaiba, 242 
Copper, 243 
Cornutine, 263 
Corpus luteum, 244, 293 
Corrosive mercuric chloride, 368 

sublimate, 368, 581 
Cosmoline, 427 
Cotarnine, 245 

hydrochloride, 245 
Counterirritants, 51, 54 
Counterirritation, 573 
Coxe's hive syrup, 102, 489 
Cream of tartar, 451 
Creolin, 245, 543 

as an antiseptic, 543 
Creosotal, 248 
Creosote, 245 

carbonate, 248 
inhaler, Yeo's, 246 



Creosote mixture, 248 

ointment, 248 

-water, 248 
Creosotum, 245 
Creta praeparata, 164 
Croton chloral, 248 

oil, 249 

liniment, 249 

tiglium, 249 
Croup kettle, 602 
Cubeba, 249 

fructus, 249 
Cubebic acid, 249 
Cubebin, 249 
Cubebs, 249 
Cucurbita pepo, 423 
Cumulative action of drugs, 45 
Cupping, 578 
Cupri sulphas, 243 
Cuprum, 243 
Cups, dry, 578 

applied, 578 

wet, 578, 579 
Curds and whey, 427 
Cusso, 250 

Cyanide of potassium, 454 
Cytisus scoparius, 475 



Dakin's fluid as an antiseptic, 539 

Dandelion, 507 

Datura stramonium, 491 

Daturine. 491 

Deadly nightshade, 137 

Decoction of azedarach, 136 

of condurango, 240 

of euphorbia pilulifera, 283 
Decoctions, 34 
Decoctum aloes compositum, 86 

granati corticis, 450 

haematoxyli, 299 

scoparii, 476 
Definition of drugs, 49 

of therapeutics, 17 
Demulcents, 51 

Denison's resistance inhaler, 600 
Deny's tuberculin, 519 
Deodorized opium, 416 
Dermatol, 146 
Deshler's salve, 458 

Diacetylmorphinse hydrochloridum, 300 
Diachylon, 350 
Dialyzed iron, 336 
Diamorphinse hydrochloridum, 300 
Diaphoretics, 51, 54 
Diastase, 250 
Diastasum, 250 
Dichloramine-T, 541 
Dichlormethane, 380 
Diet for child one year old, 647 
seven years old, 647 
six to twelve months old, 647 
two years old, 647 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



953 



Diet, importance of, in disease, 18 

lists, 646 
Dietetic treatment, importance of, 58 
Diethylmalonylurea, 137 
Diethyl-sulphon-dimethyl methane, 495 
Digalen, 259 
Digestants, 54 
Digested gruel, 646 
Digipuratum, 259 
Digitalein, 251 
Digitalin, 251, 258 
Digitalis, 251 

contraindications to, 257 

folia, 251, 258 

poisoning by, 255 

purpurea, 251 
Digitalone, 259 
Digit in, 251 
Digitonin, 251 
Digi toxin, 251 
Dihydrochloride of quinine, 221 

of dioxydiamidoarsenobenzol, 125 
Dilute acetic acid, 68 

alcohol, 82 

hydriodic acid, 306 

hydrobromic acid, 158 

hydrochloric acid, 307 

hydrocyanic acid, 307 

nitrate of silver, 390 

nitric acid, 391 

nitrohydrochloric acid, 307, 394 

phosphoric acid, 434 

solution of subacetate of lead, 349 

sulphuric acid, 499 
Dionin, 260 
Dioxydiamidoarsenobenzoldihydrochlo- 

ride, 125 
Diphtheria antitoxin, 546 
Direct action of drugs, 29 
Disease, elimination in, 19 

food in, 18 

relief of symptoms in, 19 

sleep in, 20 

treatment of, factors in, 18 
Disinfectants, 54/ 580, 581 
Disinfection, 579 

Distilled extract of hamamelis, 300 
Dithymol diiodide, 512 
Diuretics, 51, 55 
Diuretin, 482 
Dobell's solution, 149 
Donovan's solution, 120 
Dorema ammoniacum, 91 
Dormiol, 260 
Dosage, 40 

by the rectum, 43 

hypodermic, 43 

rules of, 43 

Young's rule of, 43 
Dose, "provocative," of arsphenamine in 

syphilitics, 127 
Dover's powder, 331, 416 
Dried alum, 88 

corpus luteum, 293 

sulphate of iron, 338 



Dried suprarenal gland, 502 

thyroid gland, 514 
Drip, Murphy, 875 

rectal, 875 

sheet, 561 
Drop method of giving ether, 272 

size of a, 43, 44 
Drugs, absorption of, 44 

classification of, 53 

combination of, for joint effect, 45 

cumulative action of, 45 

direct and indirect action of, 29 

duration of action, 45 

indications and contraindications 
for, 49 

modes of action of, 20 
of administering, 29 

strength and reliability of, 46 
Dry cups, 578 

applied, 578 

heat, 594 
Dryopteris filix 7 mas, 133 
Duboisia myoporoides, 261 
Duboisine, 261 

sulphate, 261 
Duquesnel's crystalline aconitine, 73 
Duration of action of drugs, 45 



Ecb allium elaterium, 261 
Ecbolic acid, 262 
Ecgonine, 226 

Effervescent citrate of magnesium, 356 
of potassium, 454 

citrated caffeine, 161 

phosphate of sodium, 485 

sulphate of sodium, 486 
Effervescing draught, 454 

powder, 478 

sulphate of magnesium, 358 
of sodium, 486 
Egg-flip, 83 

-nog, 81 
Elaterin, 261 
Elaterinum, 261 
Elaterium, 261 
Electric bath cabinet, 590 
Electuaries, 34 
Elettaria repens, 182 
Elimination in disease, 19 
Eliminators, 51, 55 
Elixir of ammonium valerate, 96 

ferri, quininse, et strychninse phos- 
phatum, 337 

glycyrrhizae, 352 

kolse composita, 342 

phosphori, 437 

roborans, 223 

terpini hydratis cum heroina, 508 
Elixirs, 34 
Emetics, 51, 55 

contraindications to, 52 



954 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Emetics, direct, 51, 55 

peripheral, 51, 55 
Emetinae hydrochloridum, 328, 331 
Emetine, 328 
Emmenagogues, 52, 55 

direct, 52, 55 

indirect, 52, 55 
Emplastra, 34 
Emplastrum arnica?, 113 

asafcetidse, 133 

belladonna?, 144 

cantharidini, 179 

cantharidis, 178 

capsici, 180 

ferri, 339 

hydrargyri, 376 

menthol, 426 

picis, 446 

burgundicae, 446 
canadensis, 446 
cantharidatum, 179, 446 

plumbi, 350 
iodidi, 349 

saponis, 481 

sinapis, 384 
Emulsin, 84, 456 
Emulsion of almonds, 84 

of asafcetida, 133 

of cod-liver oil, 236 

of sweet almonds, 84 

of turpentine, 525 
Emulsions, 35 
Emulsum amygdala?, 84 

asafcetidse, 133 

olei morrhuae, 236 

olei terebinthinae, 525 
Endermic medication, 34 
Enema, 32 

nutrient, 32 

peptonized, 645 
Enteroclysis, 582 
Epispastics, 54, 574 
Ergone, 265 
Ergot, 262 

aseptic, 265 
Ergota, 262 
Ergotic acid, 262 
Ergotin, 265 

Bonjean's, 265 
Ergotinic acid, 262 
Ergotinum, 265 
Ergotoxine, 262 
Erigeron, 265 

canadense, 265 
Erythrol tetranitrate, 394 
Erythroxylon, 226 

coca, 226 
Escharotics. 54, 574 
Eserine, 437, 439 

Esmarch's chloroform inhaler, 205 
Ether, 265 

contraindications to, 274 

"drop method" of giving, 272 

inhaler, Allis, 272 

intratracheal insufflation of, 273 



Ether, rectal administration of, for anaes- 
thesia, 275 
Ethyl alcohol, 75 

bromide, 276 

chloride, 277 
inhaler, 278 

iodide, 280 

morphine hydrochloride, 260 

salicylate, 469 
Ethylate of sodium, 484 
Ethylhydrocuprein hydrochloride, 279 
Eucaine hydrochloride, 281 

lactate, 280 
Eucalyptol, 281 
Eucalyptus, 281 

globulus, 281 
Eudoxine, 282 
Euformol, 287 
Eugenia aromatica, 225 
Eugenol, 226 
Euonymi cortex, 283 
Euonymin, 283 
Euonymus, 283 

atropurpura, 283 
Eupatorium, 283 

perfoliatum, 283 
Euphorbia pilulifera, 283 
Euphthalmin, 284 
Euquinine, 284 
Europhen, 284 
Evan's pocket inhaler, 604 
Exalgine, 285 
Exercises for treating locomotor ataxia 

and myelitis, 571 
Exogonium purga, 339 
Expectorants, 52, 55 

sedative, 52, 55 

stimulating, 52, 55 
Exsiccated ferrous sulphate, 338 

sodium arsenate, 121 
phosphate, 485 
Extract, ovarian, 293, 419 
Extracts, 35 

glandular, 293 
Extractum aconiti, 74 

belladonna? alcoholicum, 143 
foliorum, 143 
liquidum, 143 
siccum, 143 

cannabis, 177 

cascara? sagrada?, 183 
liquidum, 182 
siccum, 183 

cimicifuga?, 214 

cinchona?, 224 

liquidum, 223 

cocae liquidum, 231 

colchici, 238 
cormi, 238 

colocynthidis, 239 

compositum, 239, 474 

conii, 241 

ergota?, 265 

liquidum, 264 

euonymi, 283 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



955 



Extractum felis bovis, 419 
filicis liquidum, 134 
gelsemii, 291 
gentiana?, 292 
glycyrrhiza?, 352 

liquidum, 352 

purum, 352 
haematoxyli, 299 
hamamelidis liquidum, 300 
hydrastis, 306 

liquidum, 306 
hyoscyami, 312 
ipecacuanha? liquidum, 331 
jaborandi liquidum, 444 
jalapa?, 340 
leptandne, 351 
nucis vomica?, 404 

liquidum, 404 
siccum, 404 

opii, 416 

liquidum, 416 

siccum, 416 
pareira? liquidum, 423 
physostigmatis, 439 
pilocarpi liquidum, 444 
podophylli, 449 
rbei, 460 

sarea? liquidum, 474 
stramonii, 491 
strophanthi, 494 
sumbul, 499 
taraxaci, 507 
uva ursi, 526 



Factors in treatment of disease, 18 
Fagus. ferruginea, 246 

silvatica, 246 
Feeding the sick, 639 
Fel bovinum purificatum, 419 
Fcrri arsenas, 333 
bromidum, 334 
eacodylas, 334 

carbonas saccharatus. 332, 334 
chloridum. 332, 335 
citras, 335 

et ammonii citras. 335 
sulphas, 332, 333 
et quinina? citras, 335 
solubilis, 336 
et strychnina? citras. 335 
hydroxidum, 336 

cum magnesii oxido, 123, 336, 
356 
iodidum saccharatum, 336 
lactas, 337 
oxalas, 337 
phosphas, 337 

saccharatus, 337 
solubilis, 337 
pvrophosphas solubilis, 337 
reductum, 332, 337 
subsulphas, 332 



Ferri sulphas, 332, 338 
exsiccatus, 338 
granulatus, 338 

valeras, 338, 527 
Ferric chloride, 332, 335 

hydroxide, 336 

valerate, 338 
Ferrous arsenate, 333 

bromide, 334 

carbonate, saccharated, 332, 334 

iodide, saccharated, 336 

lactate, 337 

oxalate, 337 

sulphate, 332, 338 
Ferrum, 331 

dialvsatum, 335 

reductum, 332, 337 
Ferula fcetida, 133 
Fevers, cold in, 563 
Fibrolysin, 510 
Filix-mas, 133 
Flaxseed, 285 

meal, 286 

oil, 285 

poultice, 286 

tea. 285 
Fleabane, 265 

Fleming's tincture of aconite, 74 
Flexible collodion, 238 
Flowers of sulphur, 496 
Fluidextract of apocynum, 110 

of azedarach, 136 

of cactus grandiflorus, 161 

of condurango, 240 

of convallaria, 241 

of cubeb, 249 

of euonymus, 283 

of eupatorium, 283 

of euphorbia pilulifera. 283 

of ha?matoxylon, 299 

of hops, 305 

of piscidia erythrina, 446 

of quassia, 458 

of rhus aromatica, 461 

of sanguinaria. 472 

of savine, 474 

of solanum carolinense, 487 

of wild cherry. 457 
Fluidextracts, 35 
Fluidextractum aconiti, 74 

aromaticum, 224 

belladonna? radicis, 143 

buchu, 160 

calumba?, 168 

cannabis, 177 

capsici, 180 

cascara? sagrada?, 182 

aromaticum, 183 

cimicifuga?, 214 

cinchona?, 223 

colchici seminis, 238 

cusso, 250 

digitalis, 258 

ergota?, 264 

eucalypti, 283 



956 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Fluidextractum gelsemii, 291 

gentianae, 292 

glycyrrhizae, 352 

granati, 450 

grindeliae, 296 

Hydrastis, 306 

hyoscyami, 312 

ipecacuanhas 331 

kolse, 342 

leptandrae, 351 

lobeliae, 354 

nucis vomicae, 404 

pareirae, 423 

pilocarpi, 444 

podophylli, 449 

rhei, 461 

rosse, 462 

sarsaparillse, 474 

compositum, 474 

scillae, 489 

senegas, 478 

sennae, 479 

spigeliae, 488 

et sennse 488 

stillingiae, 490 

sumbul, 499 

taraxaci, 507 

uva ursi, 526 

veratri viride, 529 

zingiberis, 292 
Flying blister, 575 
Food in disease, 18 

materials, 639 
Foods for the sick, 639 
Formaldehyde. 286, 538, 580 

solution, 287 
Formic aldehyde 286 
Formidine, 286 
Fowler's solution, 120 
Foxglove, 251 
Fraxinus ornus, 359 
Frazier-Lentz hot-air apparatus, 593 
Fumigation, 29 

lamp for mercurial, 363 
Fusel oil, 75 



G 



Gadus morrhua, 233 
Galla, 289 
Gallic acid, 288 

ointment, 289 
Gambir, 289 
Garlic, 83 
Gaultheria, 290 

procumbens, 290 
Gavage, 585 

method of employing, 585 
Gelsemii radix, 290 
Gelsemine, 290, 291 
Gelseminine, 290 
Gelsemium, 290 

poisoning by, 291 

sempervirens, 290 



General therapeutic considerations, 17 
Gentian, 292 
Gentiana, 292 

hi tea, 292 
Gentianse radix, 292 
Gentianine, 292 
Gentisic acid, 292 
German chamomile, 360 

soft soap, 481 
Germicides, 580, 581 
Germs, mode of destroying, 580, 581 
Gin, 82, 341 
Ginger, 292 
Glacial acetic acid, 68 
Gland, pituitary, 446 

parathyroid, 423 

suprarenal, 499 

thymus, 512 

thyroid, 513 
Glandular extracts, 293 
Glaseptic nebulizer, 605 
Glauber's salt, 486 
Globulin, antidiphtheritic, 547 
Glonoin, 393 
Glusidum, 463 
Glutol, 288 
Glycerin, 293 

suppositories, 294 
Glycerins, 35 
Glycerinum, 293 

acidi borici, 295 

carbolici, 295, 433 
tannici, 295, 505 

aluminis, 88, 295 

amyli, 295 

boracis, 295 

pepsini, 295, 426 

plumbi subacetatis, 295, 350 

tragacanthae, 295 
Glycerita, 35 
Glycerities, 35 
Glyceritum acidi tannici, 505 

amyli, 295 

boroglycerini, 295 

hydrastis, 306 

phenolis, 433 

vitelli. 295 
Glycerol, 293 
Glycerole of aloes, 86 
Glycerophosphate of calcium, 164 
Glyceryl nitrate, 393, 394 
Glycyrrhiza, 352 

glabra, 352 
Glycyrrhizae radix, 352 
Glycyrrhizinum ammoniatum, 352 
Goa powder, 213 
Gold, 295 

and sodium chloride, 295 

bromide of, 157 
Golden seal, 305 
Gonolobus condurango, 240 
Goodell's pill of the three valerianates, 
527 

sumbul pill, 499 
Goulard's extract, 349 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



957 



Graduated medicine glasses, 43 

Granatum, 449 

Granulated ferrous sulphate, 338 

opium, 416 
Gray oil, 365, 375 

powder, 375 
Green soap, 481 
Griffith's mixture, 334 

pills, 334 
Grindelia, 296 

robusta, 296 
Gruel, digested, 646 
Guaiac, 296 

resin, 296 
Guaiaci resina, 296 
Guaiacol, 297 

carbonate, 298 
Guaiacolis carbonas, 298 
Guaiacum, 296 

officinale, 296 
Gum acacia, 63 

arabic, 63 



Habit, effect of, on dosage, 48 

morphine, 409 

treatment of, 410 
Town's, 411 
Haematoxyli lignum, 299 
Hematoxylin, 299 
Haematoxylon, 299 

campechianum, 299 
Hagenia abyssinica, 250 
Hamamelidis cortex, 299 

folia, 299 
Hamamelis, 299 

virginiana, 299 
Heat, 586 

dry, 594 
Heavy magnesia, 355 
Helmitol, 300 
Hemlock fruit, 240 

juice, 240 

leaves, 240 
Henbane, 311 
Heroin, 300 

hydrochloride, 300 
Herxheimer's reaction, 132 
Hexamethvlenamine (urotropin. uri- 

tone), 300 
Hexamethylen-tetramine anhydro-meth- 

ylen-citrate, 300 
Hexamine, 300 
Hoffmann's anodyne. 301 
Holocaine, 302 

hydrochloride, 302 
Homatropinae hydrobromidum, 303 
Homatropine, 303 
Home modification of Turkish bath, 589 

590 
Honev, 303 

clarified, 304 

of borax. 150, 304 

of rose, 304, 462 



Honey of squill, 489 

Hop poultice, 304 

Hope's camphor mixture, 304 

Hops, 304 

Horse-nettle, 487 

Hot-air apparatus, Frazier-Lentz, 593 

Newell's, 593 
Hot pack, 592 

mustard, 384, 592 

Springs, 617 
House mixture, 481 
Huanuco coca, 226 
Humulus, 304 

lupulus, 304 
Husband's magnesia, 356 
Huxham's tincture, 223, 480 
Hydragogue cathartics, 56 
Hydrargyri chloridum corrosivum, 368 
mite, 372 

iodidum flavum, 377 
rubrum, 371 

oleas, 376 

oxidum flavum, 377 
rubrum, 377 

perchloridum, 372 

salicylas, 377 

subchloridum, 372 

subsulphas flavus, 379 
Hydrargyrum, 360 

ammoniatum, 368 

cum creta, 375 

oleatum, 376 
Hydrastina, 306 
Hydrastine, 305, 306 
Hydrastininse hydrochloridum, 306 
Hydrastinine hydrochloride, 306 
Hydrastis, 305 

canadensis, 305 

rhizoma, 305 
Hydrate of lime, 168, 171 
Hydrated chloral, 186 
Hydriodic acid, 306 
Hydriodide of scopolamine, 477 
Hydrobromic acid, 152 
Hydrobromide of coniine, 241 

of homatropine, 303 

of hyoscyamine, 312 

of pelletierine, 449 

of quinine, 221 

of scopolamine, 312, 477 
Hydrochloric acid, 306 
Hydrochloride of apomorphine, 110, 112 

of cocaine, 226, 228 

of cotarnine, 245 

of diacetylmorphine, 300 

of emetine, 328, 331 

of ethylhydrocuprein, 279 

of ethyl morphine, 260 

of eucaine, 280 

of heroin, 300 

of holocaine, 302 

of hydrastinine, 306 

of morphine, 418 

of pelletierine, 449 

of phenocoll, 428 



958 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Hydrochloride of pilocarpine, 444 

of quinine, 221 
acid, 221 

of scopolamine, 477 

of strychnine, 404 
Hydrocyanic acid, 307 
Hydro-ergotinine, 262 
Hydrogen peroxide, 309 

as an antiseptic, 544 
Hydro-iodide of scopolamine, 477 
Hydroxide of bismuth, 148 

of iron, 336 

with magnesium oxide, 336 

of potassium, 454 

of sodium, 485 
Hyoscinae hydrobromidum, 312 
Hyoscine, 311, 477 » 

Hyoscyami folia, 311 
Hyoscyaminae hydrobromidum, 312 
Hyoscyamine, 311 

hydrobromide, 312 

sulphate, 312 
Hyoscyamus, 311 

leaves, 311 

nigra, 311 
Hypersemic treatment, Bier's, 552 
Hypnal, 313 
Hypnotics, 52, 55 
Hypodermic injection, 30 

of apomorphine, 112 
of cocaine, 231 
of ergot, 265 
of morphine, 418 

medication, 30 
Hypodermoclysis, 595, 629 

apparatus for, and method of per- 
forming, 595, 630 
Hypophosphite of calcium, 164, 166 
Hypophysis sicca, 446 
Hyposulphite of sodium, 486 



Ice-bag, 557 

-coil, 559 

-rub, 566 
Ichthyol, 314 
Idiosyncrasy, 42, 47 
Imperial drink, 451 

measure, 36 
Incompatibility, 56 
Indian hemp, 174 

poke, 528 
Indications for drugs, 49 
Indirect action of drugs, 29 
Infiltration anaesthesia, 229, 230 

method of producing, 229, 230 
Infusion of hops, 305 

of juniper, 341 

of matricaria, 360 

of pareira, 423 

of valerian, 527 

of wild cherry, 457 
Infusions, 35 



Infusum brayera?, 250 

buchu, 160 

calumbae, 168 

caryophylli, 226 

cinchonse, 223 
acidum, 224 

digitalis, 258 

ergotae, 265 

gentjanae compositum, 292 

quassise, 458 

rhei, 461 

rosae acidum, 462 

scoparii, 476 

senegas, 478 

sennae, 479 

compositum, 359, 479 

serpentariae, 480 

uvae ursi, 526 
Inhalations, 33, 596 

exercises to be used in, 597, 598, 
599 
Inhaler, Allis ether, 272 

chamber, 601 

Denison's resistance, 600, 601 

Esmarch's chloroform, 205 

ethyl chloride, 278 

Evan's pocket, 604 

Lawrie's chloroform, 206 

menthol, 425, 605 

Yeo's creosote, 246, 604 
Injectio apomorphinse hypodermica, 112 

cocainae hypodermica, 231 

ergotae hypodermica, 265 

morphinae hypodermica, 418 
Injection, hypodermic, 30 

intramuscular, 32 

intravenous, 606 
technic of, 607 

rectal, 32 
Inspissated ox-gall, 419 
Insufflation anaesthesia, 273 
Intramuscular injection, 29, 32 
Intratracheal insufflation ether anaesthe- 
sia, 273 
Intravenous injection, 29, 606 
Inunctions, 33 
Iodalbin, 315 
Iodide of ammonium, 95 

of arsenic, 120 

of ethyl, 280 

of iron, 336 

of lead, 349 

mercuric, red, 371 

mercurous, yellow, 377 

of potassium, 316 

of sodium, 320 

of strontium, 320, 492 

of thvmol, 512 
Iodine, 320 

as an antiseptic, 537 

contraindications to, 325 

ointment, 325 

poisoning by. 320 
Iodism, 319, 321 
Iodoform, 325 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



959 



Iodoform as an antiseptic, 538 

ointment, 327 

poisoning by, 326 
Iodoformum, 325 
Iodol, 327 

collodion, 328 
Iodolum, 327 
Iodothyrine, 514 
Iodum, 320 
Ipecac, 328 
Ipecacuanha, 328 
Ipecacuanha? radix, 328 
Ipecacuanhic acid, 328 
Ipomoea purga, 339 
Iron, 331 

and ammonium sulphate, 332, 333 

aromatic mixture of, 333 

arsenate of, 333 

bromide of, 334 

by hydrogen, 332, 337 

cacodylate of, 334 

carbonate of, 334 

chloride of, 332, 335 

citrates of, 335 

compound mixture of, 334 

dialyzed, 336 

hydroxide with magnesium oxide, 
336 

iodide of, 336 

lactate of, 337 

oxalate of, 337 

phosphates of, 337 

plaster, 339 

reduced, 332, 337 

subsulphate of, 332, 337 

sulphate of, 332, 338 

valerate of, 338 

wines of, 339 
Isopilocarpine, 440 



Jaborine, 440 
Jalap, 339 
Jalapa, 339 
Jalapin, 339, 474 
Jamaica dogwood, 445 
James' powder, 102 
Jamestown weed, 491 
Jasmine, yellow, 290 
Jequirity, 340 
Jervine, 528 

Joint effects of drugs, 45 
Juniper, 340 
Juniperin, 340 
Juniperus, 340 

communis, 340 

sabina, 474 
Junket, 651 



Kamala, 341 
Kaolin, 341 



Kaolin, cataplasm of, 341 
Kaolinum, 341 
Kataphoresis, 34 
Kermes mineral, 99 
Kinic acid, 214 
Kino, 342 

Kinotannic acid, 342 
Kino vie acid, 214 
Kola, 342 

Kolatannic acid, 342 
Kombe arrow-poison, 493 
Koosin, 250 
Koumyss, 646 
Kousso, 250 
Kreolin, 245, 543 

Krohne and Seseman's modification of 
Lawrie's chloroform inhaler, 207 



Labarraque's solution as disinfectant, 

539 
Laborde's rhythmic traction of tongue 

in accident by ether, 270 
Lactate of calcium, 164, 165 

of beta-eucaine, 281 

of eucaine, 280 

of iron, 337 

of strontium, 492 
Lactic acid bacillus, 343 
Lactone tablets, 643 

method of employing, 643 
Lactophenin, 70 

Lactophosphate of calcium, 164, 166 
Lactose, 495 
Lamellae atropines, 144 

cocainse, 231 

homatropina?, 303 

physostigminae, 429 
Lanolin, 344 
Lard, benzoated, 145 
Laudinine, 406 
Laudanum, 416 
Laughing gas, 396 
Lavage, 610 

methods of performing, 611 
Lavements, 32 

Lawrie's chloroform inhaler, 206 
Laxatives, 56 
Lead, 344 

acetate, 348 

carbonate, 349 

iodide, 349 

oxide, 350 

plaster, 350 

sugar of, 348 
Lead-water and laudanum, 349 

white, 349 
Lecithin, 350 
Leeches, 613 

application of, 613 

table of areas of, 614 
Leeching, 613 

therapeutics of, 613 



960 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Lemon-juice, 225 

Lenhartz treatment of gastric ulcer, 780 

Leptandra, 350 

Leptandrin, 351 

Leptandrine, 351 

Levant wormseed, 472 

Levulose, 351 

Light magnesia, 356 

Lignum vitae, 296 

Lime, 168 

chlorinated, 169 

liniment, 169 

milk of, 168 

slaked, 168, 171 

sulphurated, 170 

-water, 168 
Lindeman method of transfusion, 628 
Lingual traction, 270 
Lini farina, 286 

semina, 285 
Liniments, 35 
Linimentum aconiti, 74 

ammonias, 91 

belladonnas, 143 

calcis, 169, 286 

camphorae, 173 

ammoniatum, 173 

chloroformi, 212 

crotonis, 249 

hydrargyri, 376 

saponis, 173, 481 
mollis, 481 

sinapis, 384 

compositum, 384 

terebinthinae, 525 
aceticum, 526 
Linseed, 285 

oil, 285 

poultice, 286 
Linum, 285 

usitatissimum. 285 
Lipanin, 351 
Liquefied phenol, 433 
Liquid petrolatum, 428 
Liquor acidi arsenosi, 119, 120 
chromici, 212 

adrenalinum hydrochloricus, 502 

alumini acetatis, 88 

ammonias, 91 
fortis, 91 

ammonii acetatis, 92 
citratis, 96 

arseni et hydrargyri iodidi, 120 

arsenicalis, 119, 120 

arsenici hydrochloricus, 121 

atropinae sulphatis, 144 

bismuthi et ammonii citratis, 149 

calcis, 169 

chlorinatae, 170 
saccharatus, 171 

calumbae concent ratus, 168 

carbonis detergens, 758 

cresolis compositus, 355 

epispasticus, 178 

ferri acetatis, 339 



Liquor ferri chloridi, 335 
citratis, 335 

et ammonii acetatis, 332, 333 
perchloridi, 335 
fortis, 335 
persulphatis, 337 
subsulphatis, 337 
tersulphatis, 123 
formaldehydi, 287 
hamamelidis, 300 
hydrargyri nitratis acidus, 376 

perchloridi, 371 
hydrogenii dioxidi, 309 

peroxidi, 309 
hypophysis, 446 
iodi compositus, 325 
magnesii bicarbonatis, 356 

citratis, 356 
morphinae acetas, 418 
hydrochloridi, 418 
sulphatis, 418 
tartratis, 418 
pancreatitis, 422 
pepsini, 426 

plumbi subacetatis, 349 
dilutus, 349 
fortis, 349 
potassae, 353 
potassii arsenitis, 120 
citratis, 451, 454 
hydroxidi, 353 
permanganatis, 427 
sarsae compositus concentratus, 474 
sennae concentratus, 479 
sodse chlorinatae as an antiseptic, 

539 
sodii arsenatis, 120 
ethylatis, 484 
hydroxidi, 485 
physiologicus, 484 
strychninae hydrochloridi, 404 
thvroidei, 514 
trinitrini, 393, 394 
zinci chloridi, 532 
Liquorice, 352 
root, 352 
Liquors, 35 
Litharge, 350 
Li thia- water, 353, 616 
Lithii bromidum, 157, 353 
carbonas, 353 
citras, 353 
salicylas, 353 
Lithium, 353 

bromide, 157, 353 
Liver, 293 
Lobelia, 354 

inflata, 354 
Lobelic acid, 354 
Lobeline, 354 
Loeffler's solution, 743 
Lofoten cod-liver oil, 233 
Logwood, 299 
Lotio hydrargyri flava, 379 
nigra, 371 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



961 



Lozenges, 35 

Lugol's solution, 325 

Lumbar puncture, 614 

Lunar caustic, 387 

Lung expansion, arrangement of bottles 

for promoting, 600 
Lupulin, 304 
Lupuline, 304 
Lupulinic acid, 304 
Lupulinum, 305 
Lupulus, 304 
Lycetol, 445 
Lycopodium, 355 

clavatum, 355 
Lysol, 355 



M 



Magendie's solution, 418 
Magma bismuthi, 148 

magnesiae, 356 
Magnesia, 356 

calcined, 356 

levis, 356 

ponderosa, 356 
Magnesii carbonas, 355 
levis. 355 
ponderosus, 355 

citras, 356 

effervescens, 356 

oxidum, 356 

ponderosum, 356 

sulphas, 357 

effervescens, 358 
Magnesium, 355 
Male fern, 133 
Mai lot us Philippinensis, 341 
Malt soup, 652 
Mandrake, 448 
Manganese, 359 

sulphate, 359 
Mangani dioxidum praecipitatum, 359 
Manganum, 359 
Manna, 359 
Marsden paste, 119 
Massa copaibae, 242 

ferri carbonatis, 334 

hydrargyri, 372 
Matricaria, 360 

chamomilla, 360 

infusion of, 360 
May apple, 448 
Meadow saffron, 236 
Measures, weights and, 36 
Meconic acid, 406 
Meconine, 406 
Medication by cataphoresis, 29, 34 

endermic method, 34 

fumigation, 29 

hypodermic injection, 29, 30 

inhalation, 29, 33 

intramuscular injection, 29, 32 

intravenous, 29 

inunction, 29, 33 
61 



Medication, mouth, 29, 30 

rectum, 29, 32 

sublingual, 30 
Medicine glasses, graduated, 43 
Medinal, 137 
Mel, 303 

boracis, 150, 304 

depuratum, 304 

rosae, 304, 462 
Melaleuca leucodendron, 164 
Melia azedarach, 136 
Mentha piperta, 424 
Menthol, 424 

inhaler, 425, 605 
"Mercurettes," 375 
Mercurial fumigator, 363 

ointment, 375 
diluted, 375 

oleate, 376 

pills, 372 

plaster, 376 
Mercurialized serum, 369 
Mercuric nitrate, 376 

oxides, 377 
Mercurol, 360 
Mercury, 360 

ammoniated, 368 

as an antiseptic, 536 

bichloride, 368 

biniodide, 371 

ointment, 375 

oleate of, 376 

protiodide, 377 

salicylate, 377 

with chalk, 375 
Metadioxybenzol, 458 
Methvl acetanilid, 285 

blue, 379 

chloride, 380 

salicylas, 290 

violet, 379 
Methvlene-blue (methylthionine chlo- 
' ride), 381 

chloride, 382 

-citryl-salicylic acid, 400 
Methylsulphonal, 516 
Methylis salicylas, 290 
Methylthionine chloride (methylene- 

blue), 381 
Metric equivalents, 37, 38 

svstem of weights and measures, 37, 
38 
Mild mercurous chloride, 372 
Milk, almond, 650 

artificial, 651 

of asafcetida, 133 

of bismuth, 148 

butter-, and starch, 642 

casein, 642 

of lime, 168 

of magnesia, 356 

peptonized, 643 

-punch, 82 

peptonized, 644 

-sugar, 495 



962 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Milk of sulphur, 496 

whole, feeding for infants, 644 
Mineral astringents, 54 

cathartics, 56 

springs, 616 
Mint camphor, 425 

stearopten, 425 
Mistura ammoniaci, 91 

amygdalae, 84 

chloroformi et cannabis indicse 
composita, 193 

creosoti, 248 

cretae, 164 

ferri aromatica, 333 
composita, 334 

glycyrrhizae composita, 352 

guaiaci, 297 

olei ricini, 185 

potassii citratis, 453 

sennas composita, 479 

spiritus vini gallici, 83 
Mitigated caustic, 390 
Mixtures, 35 
Modes of action of drugs, 20 

of administering drugs, 29 
Monkshood, 70 
Monobromated camphor, 173 
Monochloral-antipyrine, 313 
Monochlor-e thane, 277 
Monochlormethane, 380 
Monohydrochloride of benzoyl, 88 
Monsel's salt, 332, 337 

solution, 337 
Moro tuberculin test, 523 
Morphina, 417 
Morphinae hydrochloridum, 417 

sulphas, 417 

tartras, 417 
Morphine, 406, 417 

habit, 409 

treatment of, 410 

Town's method of, 411 
Morrhuol, 233 
Moschus, 382 

moschiferus, 382 
Mouth, administration of drugs by, 29, 

30 
Mucilage of acacia, 63 
Mucilago acaciae, 63 
Mulled wine, 82, 651 
Muriate of ammonium, 94 

of morphine, 417 
Murphy drip, 875 
Musk, 382 
Mustard, 383 

hot pack, 384, 592 

papers, 384 

plaster, 384, 577 
Mydriatics, 52 
Myotics, 52 
Myristica, 401 

fragrans, 401 
Myrrh, 384 
Myrrha, 384 
Myrrhin, 384 



N 



Naphthalene, 385 
Naphthalenum, 385 
Naphthalin, 385 
Naphthol, 145 
Narceine, 406 
Narcotine, 406 
Nebulizer, glaseptic, 605 

Robertson's, 605 
Nebulizers, 605 
Neoarsphenamine, 125, 385 
Neosalvarsan, 125, 385 
Nervous sedatives, 52, 55 

stimulants, 52, 55 
Neutral mixture, 453 
Newell's hot-air apparatus, 594 
Newman's apparatus for proctoclysis, 

876 
Nickel, bromide of, 157 
Nitrate of mercury, 376 

of pilocarpine, 444 

of potassium, 455 

of silver, 387 

of strychnine, 404 
Nitre, 455 
Nitric acid, 390 
Nitrite of amyl, 96 

of potassium, 392 

of sodium, 392 
Nitrogen monoxide, 396 
Nitrogenii monoxidum, 396 
Nitroglycerin, 393, 394 
Nitrohydrochloric acid, 307, 394 
Nitrous oxide, 396 

administration of, 398 
contraindications to, 399 
and oxygen anaesthesia, 397 
-oxygen-ether apparatus, 398 
Normal saline solution, 484, 606 
Norwood's tincture of veratrum, 529 
Nosophen, 399 
Novaspirin, 400 
Novatophan, 400 
Novocaine, 455 
Nut-gall, 289, 504 
Nutmeg, 401 
Nutrient enema, 32, 645 
Nux vomica, 401 



Oatmeal-water, 649 
Oil of amber, 89 

Carron, 286 

of erigeron, 265 

of garlic, 83 

of gaultheria, 290 

phosphorated, 437 

of rue, 462 

of savine, 474 

of tar, 506 

of vitrol, 498 
Ointment of aconitine, 74 

of ammoniated mercury, 368 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



963 



Ointment of antimony, 102 

of atropine, 144 

of belladonna, 144 

of boric acid, 150 

of calomel, 374 

of cantharides, 179 

of capsicum, 180 

of carbolic acid, 433 

of chrysarobin, 213 

of cocaine, 231 

of conium, 241 

of creosote, 248 

of eucalyptus, 282 

of gallic acid, 289 

of galls, 289 

with opium, 289 

of hamamelis, 300 

of iodide of lead, 349 

of iodine, 325 

of iodoform, 327 

of lead acetate, 349 
carbonate, 349 
iodide, 349 
subacetate, 350 

of mercury, 375 
diluted, 375 

of nitrate of mercury, 377 

of oleate of mercury, 376 

of oxide of zinc, 532 

of phenol, 433 

of red iodide of mercury, 371 
oxide of mercury, 377 

of resin, 458 

of rose-water, 462 

of salicylic acid, 469 

of stramonium, 492 

of sulphur, 497 

of tannic acid, 505 

of tar, 506 

of tartrate of antimony, 102 

of turpentine, 526 

of veratrine, 528 

of yellow oxide of mercury, 377 
Ointments, 36 
Old tuberculin, 518 - 
Oleate of aconitine, 73 

of cocaine, 228 

of mercury, 376, 377 
Oleatum hydrargyri, 376, 377 
Oleoresina aspidii, 134 

capsici, 180 

cubebse, 250 

petroselini, 109 

piperis, 424 

zingiberis, 292 
Oleum amygdalae, 84 
amarae, 84 
expressum, 84 

cajuputi, 164 

caryophylli, 225 

chenopodii, 186 

cinereum, 365, 375 

cinnamomi, 224 

copaibae, 242 

crotonis, 249 



Oleum cubebae, 250 

eucalypti, 281 

jecoris aselli, 233 

juniperi, 341 

lini, 285 

menthae piperitae, 424 

morrhuae, 233 

myristicae, 401 

phosphoratum, 437 

picis liquidae, 506 

pimentos, 444 

ricini, 183 

santali, 471 

sinapis volatile, 383 

succini, 89 

tanaceti, 505 

terebinthinae, 524 
rectificatum, 524 

tiglii, 249 

Valerianae, 527 
Ophthalmo-tuberculin test, 522 
Opii pulvis, 416 
Opium, 406 

deodoratum, 416 

granulatum, 416 

poisoning, acute, differentiation of, 
from acute alcoholism, 80 
Opodeldoc, 481 
Optochin, 279 
Orphol, 145 
Orthoform, 418 

"new," 418 
Ouabain, 493 
Ourouparia gambier, 289 
Ovarian extract, 293, 419 
Ox-gall, 419 
Oxalate of cerium, 186 

of iron, 337 
Oxide of antimony, 99 

of calcium, 168 

of lead, 350 

of magnesium, 356 
heavy, 356 

of mercury, 377 

nitrous, 396 

of zinc, 532 
Oxygen, 419 
Oxymel, 304 

scillae, 489 
Oxytocics, 52, 56 
Oysters, peptonized, 645 



Pack, hot, 592 

Pancreas, 293 

Pancreatin, 421 

Pancreatinum, 421 

Panopsum hydrochloridum, 416 

Pantopon, 416 

Papain, 422 

Papaver somniferum, 406 

Papaverine, 406 

Papayotin, 422 



964 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Papers, 34 
Papoid, 422 
Paraldehyde, 422 
Paraldehydum, 422 
Parathyroid gland, 423 
Paregoric, 416 
Pareira, 423 
Pareirae radix, 423 
Parsley, 109 
Pearson's solution, 120 
Pelletierinae tannas, 450 
Pelletierine, 449 

hydrobromide, 449 

hydrochloride, 449 

sulphate, 449 

tannate, 449 
Pepo, 423 
Pepper, 423 

cayenne, 179 
Peppermint, 424 

-water, 424 
Pepsin, 426 

cordial, 426 
Pepsinum, 426 
Peptonized beef, 644 
enemata, 645 

milk, 643 

-punch, 644 

oysters, 645 
Percentages, table of approximate, 40 
Permanganate of potassium, 427 
Peroxide of hydrogen, 309, 544 
Persulphate of iron, 337 
Petrolatum, 427 

album, 428 

liquidum, 428 
Petroselinum, 109 
Pharmaceutical preparations, 34 
Phenacetin (acetphenetidin), 69 
Phenacetinum (acetphenetidinum), 69 
Phenazone, 104 
Phenazonum, 104 
Phenic acid, 428 
Phenocoll, 428 

hydrochloride, 428 
Phenol, 428 

as an antiseptic, 537 

glycerite of, 433 

liquefied, 433 

ointment of, 433 
Phenolphthalein, 433 
Phenolsulphonate (sulphocarbolate) of 
sodium, 433 

of zinc, 433, 544 
Phenyl-acetamide, 64 

-dimethyl-pyrazolon, 104 
Phenylic alcohol, 428 
Phenylis salicylas (salol), 469 
Phlebotomy, 637 
Phosphate of ammonium, 96 

of calcium, 164 

of codeine, 232 

of iron, 337 

of sodium, 485 

of strontium, 492 



Phosphorated oil, 437 
Phosphoric acid, 434 
Phosphorus, 434 
Phylacogens, 622 
Physostigma, 437 

venenosum, 437 
Physostigmatis semina, 437 
Physostigminae salicylas, 439 
Physostigmine, 437 
Picea, 446 

Picrasma excelsa, 457 
Picric acid, 439 
Pill of three valerianates, 527 
Pills, 35 
Pilocarpine hydrochloridum, 444 

nitras, 444 
Pilocarpine, 440 
Pilocarpus, 440 

jaborandi, 440 

microphyllus, 440 
Pilula aloes et asafetidae, 86 
et ferri, 86 
et myrrhae, 86 

colocynthidis composita, 239 
et hyoscyami, 240 

galbani composita, 133 

hydrargyri, 372 

subchloridi composita, 374 

ipecacuanhas cum scilla, 331 

plumbi cum opio, 450 

quininae sulphatis, 221 

saponis composita, 416 

scammonii composita, 475 
Pilulae aloes, 86 

et myrrhae, 385 

antimonii compositae, 102 

asafcetidae, 133 

catharticae compositae, 239 
vegetabiles, 239 

ferri, 334 

carbonatis, 334 
iodidi, 336 

phosphori, 437 

rhei, 460 

composita, 460 
compositae, 460 

scillae composita, 489 
Pimenta, 444 

officinalis, 444 
Pinkroot, 488 
Pinus palustris, 505 

svlvestris, 505 
Piper,' 423 

cubeba, 249 

nigrum, 423 
Piperazina, 444 
Piperazine, 444 
Piperine, 423 
Piscidia erythrina, 445 
Piscidine, 446 
Pitch, 446 

Pituitary gland, 446 
Pituitrin, 446 
Pix, 446 

burgundica, 446 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



965 



Pix canadensis, 446 

liquida, 505 
Plaster of arnica, 113 

of asafcetida, 133 

of belladonna, 144 

of Canada pitch, 446 

of cantharides, 178 

of capsicum, 180 

of iodide of lead, 349 

of iron, 339 

of lead, 350 

of menthol, 426 

of mercury, 376 

mustard, 384, 577 

of pitch, 446 

of soap, 481 

spice, 578 

warming, 179 
Plasters, 34 
Plumbi acetas, 348 

carbonas, 349 

iodidum, 349 

oxidum, 350 
Plumbum, 344 
Plummer's pills, 102 
Podophylli resina, 448 
Podophyllin, 448 
Podophyllum, 448 

peltatum, 448 
Poke-root, 528 
Pollen proteins, 624 
Polygala senega, 478 
Polygallic acid, 478 
Pomegranate, 449 
Port wine, 82 
Porter, 83 
Potash papers, 455 
Potassa caustica, 454 

cum calce, 168, 455, 529 
Potassii acetas, 450 

bicarbonas, 451 

bitartras, 451 

bromidum, 151 

carbonas, 451 

chloras, 452 

citras, 453 

effervescens, 454 

cyanidum, 454 

et sodii tartras, 461 

hydroxidum, 454 

iodidum, 316 

nitras, 455 

permanganas, 427 

tartras acidus, 451 
Potassium acetate, 450 

bicarbonate, 451 

bitartrate, 451 

bromide, 151 

carbonate, 451 

chlorate, 452 

citrate, 453 

cobalto-nitrite, 392 

cyanide, 454 

guaiacol-sulphonate, 509 

hydroxide, 454 



Potassium iodide, 316 

nitrate, 455 

nitrite, 392 

permanganate, 427 

silicate, 480 
Poultice of charcoal, 181 

of flaxseed, 286 

of kaolin, 341 

of starch, 490 
Poultices, 34 

Precipitated carbonate of calcium, 164 
of zinc, 531 

dioxide of manganese, 359 

phosphate of calcium, 164, 166 

sulphur, 496 
Preparations, pharmaceutical, 34 
Prepared chalk, 164 
Prescription, parts of a, 59 

writing, 58 
Pride of China, 136 
Procaine (novocaine), 455 
Proctoclysis, Newman's apparatus for, 

876 
Protargol, 456 
Proteins, pollen, 624 
Protoiodide of mercury, 374 
Protoveratrine, 528 
Protoxide of nitrogen, 396 
"Provocative dose" of arsphenamine in 

syphilitics, 127 
Pruni virginianae cortex, 456 
Prunus virginiana, 456 
Prussic acid, 307 
Pseudomorphine, 406 
Psychotria ipecacuanhas. 328 
Psychotrine, 328 
Pterocarpus marsupium, 342 
Pulvis amygdalae compositus, 84 

antimonialis, 99, 102 

aromaticus, 182, 224 

catechu compositus, 290 

cinnamomi compositus, 224 

cretse aromaticus, 165 
compositus, 165 
cum opio, 165 

effervescens compositus, 478 

elaterini compositus, 262 

glycyrrhizae compositus, 352, 479 

ipecacuanhas compositus, 331, 416 
et opii, 331, 416 

jalapae compositus, 340 

kino compositus, 342 

morphinae compositus, 418 

opii compositus, 416 

rhei compositus, 460 

scammonii compositus, 475 

sodae tartratae effervescens, 478 
Pumpkin-seed, 423 
Punch, milk,- 82 

peptonized, 644 
Punica granatum, 449 
Punk, 75 

Pure extract of glycyrrhiza, 352 
Purgatives, 56 
Purging cassia, 183 



966 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Purified chloroform, 194 

ox-gall, 419 

sulphide of antimony, 99 
Pyoktanin, 379 
Pyrogallic acid, 457 
Pyrogallol, 457 
Pyrophosphate of iron, 337 



Q 



Quassia, 457 

infusion of, 458 
Quassia? lignum, 457 
Quassin, 457 
Queen's root, 490 
Quercus, 458 

infectoria, 289 

tinctoria, 458 
Quevenne's iron, 332, 337 
Quicksilver, 360 
Quinicine, 214 
Quinidina, 214 
Quinidinse sulphas, 222 
Quinidine, 214, 222 

sulphate, 222 
Quinina, 214 
Quininse bisulphas, 221 

dihydrochloridum. 221 

et ureae hydrochloridum, 222 

hydrobromidum, 221 

hydrochloridum, 221 
acidum, 221 

sali cy las, 221 

sulphas, 221 

tannas, 221 

valeras, 221 
Quinine, 214 

acid hydrochloride of, 221 

sethyl carbon ate, 284 

and urea, bimuriate of. 222 

bisulphate, 221 

chocolates, 221 

hydrobromide, 221 

hydrochloride, 221 

salicylate, 221 

sulphate, 221 

tannate, 221 

valerate, 221, 527 



R 

Raspberry, 462 
Reaction, Herxheimer, 132 
Rectal drip, 875 

ether anesthesia, 275 

medication, 32 
Rectified spirit, 83 
Red cinchona, 214 

mercuric iodide, 371 
oxide, 377 

precipitate, 377 
ointment, 377 



Red rose, 462 

wine, 82 
Reduced iron, 332, 337 
Reliability and strength of drugs, 46 
Remedial measures other than drugs, 535 
Remedy, cold as a, 557 
Resin, 458 

cerate, 458 

compound, 458 

of guaiac, 296 

ointment, 458 
Resina, 458 

jalapae, 340 

podophylli, 449 

scammonii, 475 
Resistance inhaler, Denison's, COO 
Resorcinol, 458 
Resorcinum, 458 
Rest cure, 625 

in the treatment of disease, 20 
Restorative beef-essence, 648 
Revulsives, 52 
Rhamnus purshiana, 182 
Rhei radix, 460 
Rheum, 460 
Rhigolene, 460 ■ 
Rhubarb, 460 
Rhus aromatica, 461 

glabra, 461 
Rice-water, 649 

Richaud's table indicating areas of skin 
to which leeches or cups may be ap- 
plied, 614 
Ricinoleic acid, 183 
Ricinus communis, 183 
Robertson's nebulizer, 605 
Roborants, 52 
Rochelle salt, 461 
Rodagen, 515 
Rosa gallica, 462 

gallicae petala, 460 
Rose-water, 462 
Rosin, 458 
Rottlera, 341 
Rottlerin, 341 
Rubefacients, 54, 577, 580 
Rubi-jervine, 528 
Rubus idseus, 462 
Rue, 462 

Rules for dosage, 43 
Rum, 82 

Russian bath, 591 
Ruta graveolens, 462 



Sabina, 474 

Saccharated carbonate of iron, 332, 334 

iodide of iron, 336 

solution of lime, 171 
Saccharin (benzosulphanidum), 463 
Saccharum, 494 

lactis, 495 

officinarum, 494 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



967 



Saccharum, purificatum, 494 
Sal ethyl, 469 

prunella, 455 
Salicin, 463 
Salicinum, 463 
Salicylate of bismuth, 148 

of ethyl, 469 

of lithium, 353 

of mercury, 377 

of methyl, 290 

of phenyl (salol), 469 

of physostigmine, 439 

of quinine, 221 

of sodium, 469 

of strontium, 492 
Salicylic acid, 463 

contraindications to, 468 
ointment, 469 
poisoning by, 465 
untoward effects of, 468 
Salol (phenyl salicylate), 469 
Salophen, 471 
Salophenum, 471 
Salt, 484 
Saltpetre, 455 
Salts, 357 
Salvarsan, 125 

contraindications to, 132 

natrium, 132 

untoward effects of, 131 
Salvarsanized serum, 128 
Sandalwood oil, 471 
Sanguinaria, 472 

canadensis, 472 
Sanguinarine, 472 
Santalum album, 471 
Santonica, 472 
Santonin, 472 

poisoning by, 472 
Santoninate of sodium, 473 
Santoninic acid, 472 
Santoninum, 472 
Sapo, 481 

durus, 481 

mollis, 481 
Sarsaparilla, 473 
Savine, 474 
Scammonia radix, 474 
Scammoniae resinae, 474 
Scammony, 474 
Scarlet red, 475 
Schleich's anaesthetic fluid, 230 
Scilla, 488 
Scillin, 488 
Scillipicrin, 488 
Scillitoxin, 488 
Sclerotinic acid, 262 
Scopari cacumina, 475 
Scoparin, 475 
Scoparius, 475 
Scopola, 477 

Scopolamine hydrobromidum, 312 
Scopolamine, 477 

hydriodide, 477 

hydrobromide, 312, 477 



Scopolamine hydrochloride, 477 

morphine anaesthesia, 477 
Sedatives, cardiac, 50, 54 

nervous, 52, 55 

vasomotor, 53, 56 
Seidlitz powder, 478 
Senega, 478 
Senegae radix, 478 
Senegin, 478 
Senna, 478 

Alexandrina, 478 

confection of, 183, 479 

Indica, 478 
Sensitized vaccine, 635 
Serpent aria, 480 
Serpentariae rhizoma, 480 
Serum, antidiphtheritic, 546 

antidiphtheriticum purificatum, 546 
siccum, 547 

antidysenteric, 548 

antigonococcic, 548 

antimeningitis, 548 

antipneumococcic, 549 

antistreptococcus, 551 

antitetanicum, 550 
purificatum, 550 
siccum, 550 

mercurialized, 369 

salvarsanized, 128 
Sherry, 83 

Sick, feeding the, 639 
Silicate of. potassium, 480 

of sodium, 480 
Silver nitrate, 387 
Silvol, 481 
Sinapis alba, 383 

nigra, 383 
Sinapisma, 384 
Slaked lime, 168 
Sleep in disease, 20 
Smilax, 473 

medica, 473 

ornata, 473 
Smooth sumach, 461 
Snake-root, black, 213 

-weed, 283 
Soap, 481 

castile, 481 

green, 481 

liniment, 173, 481 

plaster, 481 
Soda caustica, 485 

tartrata, 461 
Sodii acetas, 483 

acidus, 485 

effervescens, 485 
exsiccatus, 485 

arsenas, 113, 121 
exsiccatus, 121 

bicarbonas, 483 

boras, 149 

bromidum, 157 

cacodylas, 483 

chloridum, 484 

citras, 484 



968 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Sodii et potassii tartras, 461 

hydroxidum, 485 

hyposulphis (thiosulphas), 486 

iodidum, 320 

nitris, 392 

phenolsulphonas, 433 

phosphas, 485 

salicylas, 469 

santoninas, 473 

sulphas, 486 

effervescens, 486 

sulphocarbolas, 433 

thiosulphas (hyposulphis), 486 
Sodio-benzoate, caffeine, 163 

-theobromine-salicylate, 482 
Sodium, 483 

acetate, 483 

acid phosphate, 485 

arsenate, 113, 121 
exsiccated, 121 

bicarbonate, 483 

borate, 149 

bromide, 157 

cacodylate, 483 

chloride, 484 

citrate, 484 

ethylate, 484 

hydroxide, 485 

hyposulphite (thiosulphate), 486 

ichthyol, 314 

iodide, 320 

nitrite, 392 

phenolsulphonate, 433 

phosphate, 485 
acid, 485 
effervescing, 485 
exsiccated, 485 

salicylate, 469 

salvarsan, 132 

santoninate, 473 

silicate, 480 

sulphate, 486 

sulphocarbolate, 433 

thiosulphate (hyposulphite), 486 
Soft petrolatum, 427 

soap, 481 
Solanum Carolinense, 487 
Soluble citrate of iron and quinine, 336 

glass, 480 

phosphate of iron, 337 
Solution of acetate of ammonium, 92 
of iron, 335 
of morphine, 418 

alum acetate, 88 

of ammonia, 91 

of arsenate of sodium, 120 

of arsenite of potassium, 120 

of arsenous acid, 119, 120 
and mercuric iodide, 120 

of bicarbonate of magnesium, 356 

of chloride of iron, 335 
of adrenalin, 502 
of zinc, 532 

of chlorinated lime, 171 

of chromic acid, 212 



Solution of citrate of ammonium, 96 

of bismuth and ammonium, 149 
of iron, 335 
of magnesium, 356 
of potassium, 451, 454 
Dobell's, 149 
of formaldehyde, 287 
of hydrochloride of morphine, 418 

of strychnine, 404 
of hydrogen dioxide, 309 
of iodide of arsenic and mercury, 120 
of iodine, 325 
of iron and ammonium acetate, 332, 

333 
of lime, 169 

of nitrate of mercury, 376 
normal saline, 484, 606, 861 
of pancreas, 422 
of pepsin, 426 
of perchloride of iron, 335 

of mercury, 371 
of permanganate of potassium, 427 
of potassa, 353 
of potassium citrate, 451, 454 

hydroxide, 353 
of sodium ethylate, 484 

hydroxide, 485 
of subacetate of lead, 349 
of sulphate of atropine, 144 
of iron, 338 
of morphine, 418 
of tartrate of morphine, 418 
of tersulphate of iron, 123 
Somnal, 487 
Sorghum, 494 
Soup, malt, 652 

Soya bean flour for infant feeding, 648 
Sozoiodol, 487 
Spanish fly, 177 
Sparteine sulphas, 475 
Sparteine, 475 
Sphacelinic acid, 262 
Sphacelotoxine, 262 
Spice plaster, 578 
Spigelia, 488 

marilandica, 488 
Spinal anaesthesia, mode of introducing 
the needle in, 517, 518 
extracts, 293 
Spirit of Mindererus, 92 
of nitrous ether, 503 
of turpentine, 524 
Spirits, 35 
Spiritus setheris, 275 

compositus, 301 
nitrosi, 503 
ammonise aromaticus, 91 

fcetidus, 91 
cajuputi, 164 
camphorse, 173 
chloroformi, 207, 212 
cinnamomi, 224 
frumenti, 82 

glycerylis nitratis, 393, 394 
juniperi, 341 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



969 



Spiritus juniperi compositus, 82, 341 

menthae piperita?, 424 

myristicae, 401 

odoratus, 82 

phosphori, 437 

rectificatus, 83 

vini gallici, 82 
Sponging, cool, 566 
Sprays, atomized, 33 
Springs, hot, 617 

mineral, 616 
Squill, 488 

Squirting cucumber, 261 
Starch, 490 

buttermilk and, 642 

glycerite of, 295 

poultice, 490 

-water, 490 
Steam vaporizer, 603 
Steapsin, 421 
Stearosan, 471 
Stillingia, 490 

sylvatica, 490 
Stillingin, 490 
Stimulants, cardiac, 50, 54 

nervous, 52, 56 

vasomotor, 53, 56 
Stomach-pump, 613 
Stout, 82 
Stovaine, 491 
Stramonii folia, 491 
Stramonium, 491 
Strength, relative, of drugs, 46 
Stretcher, bath, 567 
Stronger water of ammonia, 91 
Strontii bromidum, 492 

iodidum, 320, 492 

salicylas, 492 
Strontium, 492 

bromide, 492 

iodide, 320, 492 

lactate, 492 

phosphate, 492 

salicylate, 492 
Strophanthi semina, 493 
Strophanthidin, 493 
Strophanthin, 493 
Strophanthinum, 493, 494 
Strophanthone, 494 
Strophanthus, 493 

gratus, 493 

hispidus, 493 

kombe, 493 
Strychninae nitras, 404 

sulphas, 404 
Strychnine, 401 

hydrochloride, 404 

nitrate, 404 

sulphate, 404 
Strychnos nux vomica, 401 
Styptic collodion, 239, 505 
Stypticin, 245 
Styrax benzoin. 144 
Subcarbonate of bismuth, 146 
Subgallate of bismuth, 146 



Sublimed sulphur, 496 
Sublingual medication, 30 
Subnitrate of bismuth, 146 
Subsalicylate of bismuth, 148 
Subsulphate of iron, 332, 337 
Succinum, 89 
Succus belladonnas, 144 

conii, 241 

limonis, 225 

scoparii, 476 

taraxaci, 507 
Sugar, 494 

beet-, 494 

-cane, 494 

of lead, 348 

of milk, 495 
Sulphate of aluminum and potassium, 87 

of ammonium, 96 

of atropine, 138, 143 

of calcium, 167 

of cinchonidine, 223 

of cinchonine, 223 

of codeine, 232 

of copper, 243 

of duboisine, 261 

of hyoscyamine, 312 

of iron, 332, 338 

and ammonium, 332, 333 

of magnesium, 357 

of morphine, 417 

of pelletierine, 449 

of physostigmine, 439 

of quinidine, 223 

of quinine, 221 

of sodium, 486 

of sparteine, 475 

of strychnine, 404 

of zinc, 533 
Sulphide of antimony, 99 
Sulphocarbolate (phenolsulphonate) of 
sodium, 433 

of zinc, 433 
Sulphonal (sulphonmethane), 495 
Suiphonalum, 495 

Sulphonethylmethanum (trional), 516 
Sulphonmethanum (sulphonal), 495 
Sulphur, 496 

lotum, 496 

milk of, 497 

ointment, 497 

praecipitatum, 496 

springs, 618 

sublimatum, 496 
Sulphurated antimony, 99 

lime, 170 
Sulphuric acid, 498 

lemonade, 499 

ether, 265 
Sumach, smooth, 461 

sweet, 461 
Sumbul, 499 

pill, Goodell's, 499 

radix, 499 
Suppositoria acidi tannici, 505 

belladonnae, 144 



970 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Suppositoria glycerini, 294 
iodoformi, 327 
morphinse, 418 
plumbi composita, 349 
Suppositories, 33, 35 

of asafoetida, 133 
Suppositorium acidi carbolici, 433 
Suprarenal gland, 499 
Suprarenalum siccum, 502 
Swamp hellebore, 528 
Sweet almonds, 83 

spirit of nitre, 503 
sumach, 461 
Sydenham's laudanum, 416 
Symptoms, relief of, in disease, 19 
Syrups, 35 
Syrupus acaciae, 63 
acidi citrici, 225 

hydriodici, 306 
allii, 83 

calcii lactophosphatis, 166 
cascarse aromaticus, 183 
chloral, 190 

codeinse phosphatis, 233 
ferri bromidi, 334 
iodidi, 336 
phosphatis, 337 

cum quinina et strychnina, 
337 
quininse et strychninse phos- 
phatum, 337 
hypophosphitum, 166 

cum ferro, 337 
ipecacuanha?, 331 
limonis, 225 
picis liquidse, 506 
pruni virginianse, 457 
rhei, 461 

aromaticus, 461 
rosse, 462 
rubi idsei, 462 

sarsaparillse compositus, 474 
scillse, 489 

compositus, 102, 489 
senegse, 478 
sennae, 479 
zingiberis, 292 



Tabell/e trinitrini, 394 
Table of approximate percentages, 40 
Richaud's indicating areas of skin 
to which leeches or cups may be 
applied, 614 
comparative, showing strengths of 
substances and preparations in 
preceding and present pharma- 
copoeia, 9 
Tables of relative weights and measures 
in the metric and apothecaries' sys- 
tems, 39 
Tablet triturates, 36 
Tablets, 35 



Tablets of nitroglycerin, 394 
Taeniin, 250 
Taka-diastase, 250 
Tamarinds, 504 
Tamarindus, 504 
Tanacetum, 505 

vulgare, 505 
Tannate of pelletierine, 449 

of quinine, 221 
Tannic acid, 504 
Tansy, 505 

tea, 505 
Tar, 505 

oil of, 506 

ointment, 506 

-water, 506 

wine of, 506 
Taraxacum, 507 
Tartar emetic, 99, 102 
Tartaric acid, 507 
Tartrate of antimony and potassium, 99 

of morphine, 417 

of potassium and sodium, 461 
Tea, beef-, 648 

flaxseed-, 285 
Temperament, effect of, on dosage, 48 
Terebene, 507 
Terebenum, 507 
Terebinthina, 524 
Terminal infections, 22 
Terpine hydrate, 508 
Terpini hydras, 508 
Terpinol, 508 

Test, tuberculin, Moro, 523 
ophthalmo, 522 
von Pirquet's, 523 
Testicular juice, 293 
Thapsia, 509 

garganica, 509 
Thea sinensis, 161 
Thebaine, 406 
Theine, 161 
Theobroma cacoa, 226 
Theobromine et sodii salicylas, 482 

sodiosalicylas, 482 
Theobromine, 342 

sodiosalicylate, 482 
Theocin, 509 
Theophyllina, 509 

Therapeutical considerations, general, 17 
Therapeutics, definition of, 17 
Thiocol, 509 
Thiosinamine, 510 
Thiosulphate of sodium, 486 
Thoroughwort, 283 
Thymol, 511 

iodide, 512 
Thymus glands, 512 
Thyroid gland, 293, 513 
Thyroidectin, 515 
Thyroideum siccum, 514 
Thyroiodine, 514 
Thyroprotein, 515 
Tinctura aconiti, 74 

aloes, 86 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



971 



Tinctura aloes et myrrhae, 385 
arnicas, 113 

florum, 113 

radicus, 113 
asafcetidas, 133 
belladonnas, 143 

foliorum, 143 
benzoini, 145 

composita, 145 
bryonias, 159 
buchu, 160 
calumbas, 168 

camphoras composita, 173, 416 
cannabis, 177 
cantharidis, 178 
capsici, 180 
cardamomi, 182 

composita, 182 
catechu, 290 
chloroform! et morphinas composita, 

212, 418 
cinchonas, 223 

composita, 223, 480 
cinnamomi, 224 
colchici, 238 

seminis, 238 
conii, 241 
convallarias, 242 
cubebse, 249 
digitalis, 258 
ergotas ammoniata, 265 
ferri chloridi, 335 

perchloridi, 335 
gambir composita, 289 
gelsemii, 291 
gentianas composita, 292 
guaiaci, 297 

ammoniata, 297 
hamamelidis, 300 
hydrastis, 306 
hyoscvami, 312 
iodi. 325 

fortis, 325 

mitis, 325 
ipecacuanhas et opii, 416 
jaborandi, 444 
jalapas, 340 
kino, 342 
lobelias, 354 

astherea, 354 
moschi, 383 
myrrhas, 385 
nucis vomicas, 404 
opii, 416 

ammoniata, 416 

camphorata, 416 

deodorati, 416 
physostigmatis, 439 
podyphylli, 449 
pruni virginianas, 457 
quassias, 458 
quininas, 221 

ammoniata, 221 
rhei, 461 

aromatica, 461 



Tinctura rhei composita, 461 
dulcis, 461 

sanguinarias, 472 

scillas, 489 

senegas, 478 

sennas composita, 479 

stramonii, 492 

strophanthi, 494 

sumbul, 499 

valerianas, 527 

ammoniata, 527 

veratri viridis, 529 

zingiberis, 292 
Tincture of apocynum, 110 

of cactus grandiflorus, 161 

of hops, 305 

of muriate of iron, 335 
Tinctures, 35 

changes in strength of, 62 
Toast, watered, 644 
Toluene dichloramine, 541 

sulphondichloramine, 541 
Tongue, Laborde's rhythmic traction of, 

in accidents by ether, 270 
Tonics, 53, 56 
Touchwood, 75 
Town's method of treating the morphine 

habit, 411 
Toxitabellas hydrargyri chloridi corrosivi, 

371 
Transfusion, 627 

apparatus, 630 

Lindeman method of, 628 

method of injection in, 628 
Tribromomethane, 158 
Tribromphenol-bismuth, 530 
Tribrom-tertiary-butyl-alcohol, 150 
Trichloracetic acid, 515 
Trichlormethane, 194 
Trikresol, 515 
Trimethol, 516 

Trimethyl-methoxy-phenol, 516 
Trinitrin, 393 
Trinitrophenol, 439 
Trional (sulphonethylmethane), 516 
Trioxide, arsenic, 113, 120 

chromium, 212 
Triturates, 35 
Trituratio elaterini, 262 
Troches, 35, 36 
Trochisci acidi tannici, 505 

cretas, 165 

cubebas, 250 

ferri redacti, 337 

gambir, 289 

ipecacuanhas, 331 

magnesias, 356 

menthas piperitas, 424 

morphinas et ipecacuanhas, 331, 418 

potassii chloratis, 453 

santonini, 473 

sodii santoninatis, 473 

zingiberis, 292 
Trochiscus acidi benzoici, 145 
carbolici, 433 



972 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



Trochiscus acidi tannici, 505 

catechu, 290 

guaiaci resinae, 297 

kino eucalypti, 282 

morphinae, 418 

et ipecacuanha?, 331, 418 

sulphuris, 498 
Tropacocaine, 517 
Tropic acid, 303 
Tropine, 303 
Truxillo coca, 226 
Trypsin, 421 
Tuberculin, 518 

B. E., 519 

bouillon filtrate, 519 

Denys', 519 

old, 518 

ophthalmo-, test, 522 

residua turn, 519 

skin test, 523 
Tully's powder, 418 
Turkish bath, 587 

home modification of, 589, 590 
Turpentine, 524 

linament, 525 

oil of, 524 

ointment, 526 

stupe, 524, 578 
Turpeth mineral, 379 



Unguents, 36 

Unguentum acidi borici, 150 

carbolici, 433 

gallici, 289 

salicylici, 469 

tannici, 505 
aconitinae, 74 
antimonii tartrati, 102 
aquae rosae, 462 
atropinae, 144 
belladonnae, 144 
cantharidis, 179 
capsici, 180 
cetacei, 145 
chrysarobini, 213 
cocainae, 231 
conii, 241 
creosoti, 248 
eucalypti, 282 
gallae, 289 

cum opii, 289 
glycerini plumbi subacetatis, 295 
hamamelidis, 300 
hydrargyri, 375 

ammoniati, 368 
dilutum, 375 

iodidi rubri, 371 

nitratis, 377 

dilutum, 377 

oleatis, 376 

oxidi flavi, 377 
rubri, 377 



Unguentum hydrargyri subchloridi, 374 

iodi, 325 

iodoformi, 327 

petrolei, 427 

phenolis, 433 

picis liquidae, 506 

plumbi acetatis, 349 
carbonatis, 349 
iodidi, 349 
subacetatis, 350 

resinae, 458 

stramonii, 492 

sulphuris, 497 

zinci oxidi, 532 
Unit, antidiphtheritic, 547 
Unna's dressing, 532 
Urginea maritima, 488 
Uritone, 300 

Uro tropin (hexamethylenamine), 300 
Ursin, 526 
Uva ursi, 526 
Uvae ursi folia, 526 



Vaccine, therapy, 631 

prophylactic, 631 

sensitized, 635 
Valerate of ammonium, 96, 527 

of iron, 338, 527 

of quinine, 221, 527 

of zinc, 527 
Valerian, 526 
Valeriana, 526 

officinalis, 526 
Valerianae rhizoma, 526 
Valerianic acid, 526, 527 
Vallet's mass, 334 
Vapor acidi hvdrocyanici, 309 

chlori, 170 

conii, 241 
Vaporization, 33 
Vaporizer, steam, 603 
Vaseline, 427 
Vasomotor depressants, 53, 56 

stimulants, 53, 56 
Vegetable astringents, 54 

cathartic pills, 239 

cathartics, 56 
Venesection, 637 
Veratri viridis rhizoma, 528 
Veratrina, 527 
Veratrine ointment, 528 
Veratroidine, 528 
Veratrone, 529 
Veratrum viride, 528 
Veronal, 137 

sodium, 137 
Veronica virginiana, 350 
Vienna mixture, 207 

paste, 455, 529 
Vinegar, 68 

of ipecac, 331 

of lobelia, 354 



INDEX OF DRUGS AND REMEDIAL MEASURES. 



973 



Vinegar of opium, 416 

of sanguinaria, 472 

of squill, 489 
Vinegars, 34 
Vinum colchici, 238 
seminis, 237 

ferri citratis, 339 

opii, 416 

picis, 506 

portense, 82 

quininse, 221 

xericum, 83 
Virginia snake-root, 480 
Vitriol, oil of, 498 
Volatile oil of, mustard, 383 
von Pirquet tuberculin test, 523 



W 

Wahoo, 283 
Warburg's tincture, 530 
Warming plaster, 179, 446 
Wash, black, 371 

yellow, 379 
Washed sulphur, 496 
Water of ammonia, 91 
stronger, 91 

barley-, 649 

bitter almonds, 84 

camphor, 173 

cinnamon, 224 

creosote, 248 

chloroform, 207, 212 

lead-, and laudanum, 349 

lime-, 168 

oatmeal-, 649 

peppermint, 424 

pimenta, 444 

rice-, 649 

rose, 462 

starch, 490 

tar, 506 
Watered toast, 652 
Waters, 34 

lithia, 616 
Weights and measures, 36 

tables of relative, 39 

apothecaries', 36 

avoirdupois, 36 

metric, 37, 38 
Wet cups, 578, 579 
Whey, curds and, 427 

wine-, 82, 649 
Whisky, 82 
White ginger, 292 

lead, 349 

mustard, 383 

oak, 458 

petrolatum, 428 

precipitate, 368 



White precipitate ointment, 368 

wine, 82 
Whytt's tincture, 223 
Wild cherry, 456 
Wine, 82 

of colchicum, 238 
-seed, 237 

of condurango, 240 

measure, 36 

mulled, 82, 651 

of opium, 416 

port, 82 

of quinine, 221 

red, 82 

of tar, 506 

whey, 82, 649 

white, 82 
Wines, 36 
Wlntergreen, 290 
Witch-hazel, 299 
Wormseed, American, 186 

Levant, 472 



Xanthoptjccin, 305 
Xeroform, 530 



Yellow gentian, 292 
jasmine, 290 
mercuric oxide, 377 
mercurous iodide, 377 
prussiate of potassium, 243 
pyoktanin, 379 
sulphate of mercury, 379 
wash, 379 
Yeo's creosote inhaler, 246, 604 
Yolk of egg, glycerite of, 295 
Young's rule for dosage, 43 



Z 



Zea mays, 490 
Zinc sozoiodol, 487 
Zinci acetas, 531 

carbonas, 531 

prsecipitatus, 531 

chloridum, 532, 544 

oxidum, 532 
venale, 532 

phenolsulphonas, 433, 544 

sulphas, 533 

sulphocarbolas, 433 

valeras, 527 
Zingiber, 292 

officinale, 292 



INDEX OF DISEASES AND REMEDIES. 



ABORTION, 655 

Cascara sagrada, or compound liquorice 
powder as a laxative for associated con- 
stipation; if these fail, rhubarb or castor 
oil, 655 

Creolin (2 per cent, solution) should be 
injected after removal of the membranes, 
or if fever should follow, 657 

Curettement, 657 

Diet and hygiene, 655 

Elaterium, jalap, scammony, strychnine, 
erigeron, cantharides, coatraindicated, 
unless very necessary, 655 

Ergot and quinine, in small doses with 
perfect rest for one or two weeks, and 
antiseptic irrigation as an after-treat- 
ment, 656 

Iodine, applied to the inner surface of 
uterus, after removal of membranes, as 
a haemostatic and antiseptic, 657 

Opium or morphine, best agents to quiet 
uterus if abortion threatens, 656 

Podophyllin, senna, salines in active doses, 
and aloes, not to be used if they can be 
avoided, 655 

Quinine, useful in malarial poisoning, as a 
preventive; in other cases contraindi- 
cated, 656 

Saline purges contraindicated, except in 
plethoric women, 655 

Sponges should not be used as tampons, 
656 

Tampons of absorbent cotton, dusted with 
iodoform, followed later by ergot, if 
abortion is inevitable, 656 

Venesection, useful in plethoric women to 
prevent, 656 

Viburnum prunifolium, fluidextract, drachm 
| to 1 (2.0-4.0), taken during pregnancy 
as a prophylactic; 656 

ABSCESS, 657 

Aconite or veratrum in full dose may abort, 
657 

Alcohol, given with milk, in cold abscess, 
658 

Belladonna ointment, locally applied to 
abort; or tincture, internally, if aconite 
is not at hand, 657 

Calx sulphurata, gr. ^ (0.006) every hour 
or two, useful to abort or cause absorp- 
tion, 658 

Cod-liver oil with hypophosphites, quinine 
and iron, useful in cold abscess, 658 

Hydrogen peroxide, 3 per cent, solution, 
to wash out cavity of tubercular or slow 
abscess, 310, 658 

Incision, if pus forms, followed by irriga- 
tion, with phenol (1:20) or bichloride 
solution (1 : 5000) and antiseptic dress- 
ing, 658 



Iodine, locally applied, may abort, 658 
Iodoform gauze, packed into cavity, or 
ethereal solution injected after aspira- 
tion, and antiseptic dressing, useful in 
tubercular abscess, 658 
Lead-water, applied on bread-crumb poul- 
tice or lint, in early stage, to abort, 657 
Nitrate of silver, gr. 20 to 40 (1.3-2.6) to 
the ounce (30.0), locally applied, may 
abort, 657 
Phenol, minims 5 to 10 (0.3-0.6) of 2 per 
cent, solution, injected into gland threat- 
ening suppuration, 657 
Poultices to assist maturation, 658 
Prescriptions for tonics, in cold abscess, 658 
Quinine bihydro chloride solution to steri- 
lize cavity in amoebic abscess of liver 
after aspiration of the pus, 220. 

ACETONURIA. 

Chloroform contraindicated, 211 



ACIDITY. 

Ammonia, the most active remedy in gas- 
tric acidity, contraindicated if acute 
irritation exists, 91 

Bicarbonate of sodium in form of efferves- 
cing powder, valuable in gastric acidity, 
483 

Bismuth, a slow and feeble antacid, 147 

Carbonate of calcium, precipitated, best 
antacid in intestinal acidity, 164 

Cerium oxalate, used in some cases of gas- 
tric acidity instead of bismuth, 186 

Charcoal, useful in some cases of "sour 
stomach," 181 

Lime-water, 168 

Liquor potassii hydroxidi, useful both for 
gastric and urinary acidity, 353 

Magnesium, a useful antacid, 355 

ACNE, 659 

Calx sulphurata, gr. ^ to \ (0.006-0.03), in 
pill, thrice daily, in pustular acne, 170, 
659 

Cod-liver oil, if scrofulosis exists, 659 

Fowler's solution, often cures and prevents 
relapse, dose 1YI 1 to 3 (0.06-0.2) thrice 
daily, for a month or two, 659 

Green or Castile soap, used in face-bath 
night and morning, followed by brisk 
rubbing; if irritation ensues, simple 
cerate or emulsion of bitter almonds will 
relieve, 660 

Ichthyol, 20 to 100 parts of lard, well 
rubbed in, when induration is great, 315, 
660 

Mercurial ointment, to relieve induration, 
several days intervening between its 
use and that of sulphur, 660 

(975) 



976 



INDEX OF DISEASES AND REMEDIES. 



Phenol, touched to pustules after incision, 
660 

Phosphorus, especially useful in acne indu- 
rata, 437 

Resorcinol, gr. 10 to 20 to the ounce (0.6- 
1.3 : 30.0) of lard, when induration is 
great, 660 

Saline purges, followed by cascara sagrada 
or similar remedy, to regulate bowels, if 
dependent upon obstinate constipation, 
659 

Sulphur, internally and as a wash or oint- 
ment, for women with disordered men- 
struation, prescription for, 498, 659 

ACTINOMYCOSIS. 

Potassium iodide, useful in full doses, 319 

ADENITIS, 660 

Ichthyol, prescription for, 660 

Iodine ointment and lard, equal parts, 
applied by inunction night and morning, 
or tincture, as a paint, stopping appli- 
cation on appearance of redness or fluc- 
tuation, 660 

Iron, syrup of the iodide, Tfl. 5 to 20 (0.3- 
1.3), in children, 660 

Lancing, preferable to allowing abscess to 
break, 661 

Poultice, when redness or fluctuation ap- 
pears, 660 

Removal of gland by dissection, if enlarge- 
ment is scrofulous, 661 

Tonics, to improve systemic condition, 660 

ALBUMINURIA. (See Bright's 
Disease.) 

Cacodylate of iron, in albuminuria of tuber- 
culosis, 334 

Calcium chloride or lactate, if due to altera- 
tions in the blood, 166 

Cantharides, useful in later stages of nephri- 
tis, 178 

Gallic acid, if due to atony of kidneys, 288 

Juniper, in albuminuria due to congestion, 
341 

Strontium lactate, if due to renal atony, 492 

ALCOHOLISM. (See Poisoning from 
Alcohol.) 

ALOPECIA, 661 

Chrysarobin, drachm \ to 1 (2.0-4.0), to 
lanolin, 1 ounce (30.0), 661 

Corrosive sublimate, gr. 2 (0.12), to recti- 
fied spirit 1 drachm (4.0) and oil of 
turpentine 7 drachms (28.0), 661 

Liquor epispasticus, painted over bald spot 
after loose hairs have been depilated, 661 

Pilocarpine, locally applied, often stimu- 
lates new growth; too much causes small 
pustules around follicles; prescription 
for, 443 



AMAUROSIS AND AMBLYOPIA, 661 

Cauterization of nape of neck, 662 
Correction of optical errors, when arising 
from congenital trouble or non-use, 662 
Cups, wet and dry, 662 



Digitalis, in toxic cases, 663 

Electricity, constant current, 663 

Emmenagogues, if due to menstrual dis- 
orders, 662 

Iodide of potassium, 662 

Metallo-therapy, may be tried in hysterical 
cases, 662 

Nitroglycerin, 663 

Nux vomica, in ascending doses in tobacco 
or alcoholic cases, 402 

Pilocarpine, in uraemic, tobacco, or alcohol 
amaurosis, 442 

Strychnine, hypodermically, after irrita- 
tion has subsided, 663 

AMENORRHEA, 664 

Aloes, as a specific, when dependent upon 
constipation, atony of sexual system, or 
anaemia, 86, 664 

Apiol, 1U 3 to 10 (0.2-0.6), in capsule, thrice 
daily for a week before date of men- 
struation, 109, 665 

Arnica, 113 • 

Cantharides, as a stimulant, if due to atony 
or depression, 177 

Cimicifuga, fluidextract, ffl 30 (2.0), at the 
proper time for a flow, 214, 664 

Corpus luteum seems to do good, 244 

Dewees' emmenagogue mixture, 665 

Dioxide manganese, gr. 1 to 3 (0.06-0.2), 
taken for two weeks before time of men- 
struation, 359. 664 

Eupatorium, in hot infusion, if due to cold, 
283 

Goodell's prescription for, 664 

Griffith's pills, largely used when dependent 
upon anaemia, 334 

Hot sitz-bath, for several nights before 
period, mustard added often increases 
its efficacy, 665 

Iron and myrrh, a standard remedy if due 
to atony or anaemia, 384 

Oil of rue, 1U 5 (0.3), in capsule, thrice 
daily, 665 

Potassium permanganate, useful, but infe- 
rior to dioxide of manganese, 427, 664 

Salines inferior to aloes if due to constipa- 
tion, 664 

Savine, Til 5 (0.3), in capsule, thrice daily, 
to stimulate uterus, 474, 665 

Tansy, 111 5 (0.3), in capsule, thrice daily, 
or in form of tansy tea, 505. 665 

ANEMIA, 665 

Aromatic mixture of iron, 333 

Arsenate of iron in anaemia of chronic 

diarrhoea, 333 
Arsenic, not to exceed gr. y 1 ^ (0.006) daily, 

alone or combined with iron, valuable, 

668; very valuable in pernicious and 

malarial anaemia, 115 
Bitters, simple or aromatic, in conjunction 

with iron, when stomach and intestines 

are atonic, 667 
Blaud's pill, 668 
Bromide of iron, gr. 5 to 20 (0.3-1.3), in 

syrup, useful when there is chorea, 334 
Cacodylate of iron, when haemoglobin and 

corpuscles are lacking, 334 
Carbonate of iron, 334, 667 
Cerebral and spinal extracts, useless in 

pernicious anaemia, 293 



INDEX OF DISEASES AND REMEDIES. 



977 



Chloride of iron, useful because of its tonic 
properties, 335 

Citrate of iron intramuscularly, 668 

Copper arsenite, 244, 668 

Dialyzed iron, 336 

Diet and hygiene, 669 

Dried corpus luteum in chlorotic type, 293 

Hypophosphites and phosphate of lime, 
with cod-liver oil, iron, and quinine, 
when anaemia is due to childbearing and 
lactation, 165, 668 

Iodide of iron, syrup of, largely used in 
strumous and scrofulous anaemia, 322, 
336 

Iron, 332, 666 

Mercury, bichloride or calomel, especially 
valuable in syphilitic cases. Inunctions 
of mercurial ointment, once a day or 
every other day, of service, in all forms 
of anaemia, 370, 668 

Ovarian extract in chlorosis, 293 

Oxygen inhalations of value, 419 

Phenyl salicylate, when due to decomposi- 
tion-products, 470 

Quevenne's iron, 337, 667 

Quinine in malarial cases, and in tonic doses 
in all other anaemias, 667 

Reduced iron, with laxatives and mineral 
acids for their effects on intestines and 
liver in uncomplicated cases, 337, 667 

Rest cure, 626 

Rockbridge alum-water in diarrhoea with 
anaemia, 618 

Salvarsan or neosalvarsan may be used in 
some cases of pernicious anaemia, 669 

Sodium cacodylate in anaemia of tubercu- 
losis, 483 

Sulphate of iron in diarrhoea with anaemia, 
338, 667 

Thymol as an intestinal antiseptic, 667 

Transfusion in pernicious anaemia, 627 

ANAL FISSURE, 669 

Belladonna ointment or suppository in 
spasm of the sphincter due to fissure, 142 

Castor oil, to relieve bowels, if sulphur 
cannot be used, 669 

Flexible collodion, painted over spot, may 
relieve, 669 

Ichthyol, pure, applied locally, 669 

Iodoform suppositories, gr. 2 to 10 (0.12- 
0.6), relieve pain of defecation; bella- 
donna, gr. 4 (0.015), to be added when 
there is spasm of sphincter, 327, 669 

Phenol, 1 drop, applied to fissure to effect 
cure; in addition, when hemorrhoids are 
present, a lotion of tannic acid, glycerin, 
and water, 669 

Potassium bromide, drachms 1| to the 
ounce (6.0-30.0) of glycerin, locally 
applied to fissure by means of a brush, 
highlv recommended, 669 

Sulphur, gr. 20 to 40 (1.3-2.6), combined 
with powdered cinnamon or aromatic 
powder, at night, to render passages soft, 
669 

ANAPHYLAXIS. 

Atropine, in large dose, the best remedy, 
142 

ANEURYSM, 670 

Aconite, inferior to veratrum as a cardiac 
sedative, 670 

62 



Chloroform inhalation, if dyspnoea is great, 
670 

Digitalis, contraindicated, 670 

Electrolysis, 670 

Iodide of potassium, in large doses, asso- 
ciated with restricted diet and rest in 
bed; more valuable in syphilitic than in 
other forms of the disease, 318, 670 

Morphine, gr. f (0.008), combined with 
hydrated chloral or, better, with croton 
chloral, gr. 10 (0.6), in sleeplessness due 
to pain, 670 

Veratrum, TU 4 to 8 (0.25-0.5), twice or 
thrice daily if heart is excitable and 
vascular tension high, 529, 670 

ANGINA PECTORIS, 671 

Alcohol, instead of nitrites, when there is 

vascular relaxation, 671 
Digitalone, when heart is weak, 671 
Donovan's solution useful, 672 
Ether, in 1-drachm (4.0) doses in ice-water 

or capsule, to nervous females, often 

aborts, 671 
Hoffmann's anodyne, often the best 

remedy, 302, 671 
Morphine, gr. \ to \ (0.105-0.03), hypo- 

dermically, when nitrite of amyl fails to 

relieve, 672 
Nitrite of amyl, inhalation of a few drops 

from handkerchief during attack, 97, 671 
Nitrite of sodium or potassium, gr. 3 (0.2) 

thrice daily, useless unless arterial ten- 
sion is high and heart throbbing, 392, 671 
Nitroglycerin, m 1 (0.06) of the official spirit 

during attack, 393, 671 
Prescription for use between attacks, 672 
Stomach-pump, may be required when due 

to overloaded stomach, 672 
Tonics, combined with careful diet and 

hygiene necessary to a cure, 672 

ANGIOMA. 

Carbon-dioxide snow, 556 

ANOREXIA, 672 

Calomel, useful when following acute dis- 
ease; nitro-muriatic acid, however, gen- 
erally preferable, 374 

Capsicum, in convalescence, acts most 
favorably, 180 

Eupatorium, useful in, 283 

Gentian, 292 

Prescriptions for tonics, 673 

Quassia, especially valuable when following 
malarial fever, 457 

APHONIA. 

Chlorine gas has been used in aphonia due 
to cold, 170 

APOPLEXY, 673 

Belladonna, hypodermically, if respiration 

fails, 674 
Calomel, gr. \ (0.015) every four hours, if 

symptoms of meningitis arise, 674 
Croton oil, 1U 1 (0.06), with sweet oil, TTl 5 

(0.3), as a depletant cathartic, 673 
Diet, 674 



978 



INDEX OF DISEASES AND REMEDIES. 



Elaterium, gr. | (0.01), as a depletant 
cathartic, 673 

Ice to the head, 673 

Iodide of potassium, in large doses several 
days after attack, when clot has firmly 
formed, to promote absorption, 674 

Massage and electricity, applied to muscles 
to prevent atrophy; contraindicated if 
inflammation exists, 674 

Mercury, 674 

Mustard plaster to feet, or mustard foot- 
bath and ice to head, keeping head high 
and feet low, 673 

Stimulants contraindicated, 674 

Strychnine, hypodermically, if respiration 
fails, is also useful to stimulate trophic 
centres in cord, 674 

Venesection, if patient is full-blooded, to 
prevent inflammation and further leak- 
age, 637, 674 

APPENDICITIS, 674 

Absolute rest necessary, 675 

Opium or morphine (after the bowels have 

moved), to relieve pain and act as an 

antiphlogistic, 675 
Rules for treating, 676 
Surgical treatment, 675 

ARTHRITIS. 

Bicarbonate of sodium, applied to part on 
lint, to ally pain, 483 

Lactic acid bacilli used in rheumatoid ar- 
thritis, 344 

Lithium carbonate and citrate prevent 
deposit in joints from rheumatoid arthri- 
tis, 353 

Mustard plaster as a counterirritant, 3S3 

Salicylic acid valueless in rheumatoid 
arthritis, 466 

Veratrine ointment, 528 

ASCARIS LUMBRICOIDES. 

(See Worms.) 



ASCITES. (See Dropsy.) 



ASPHYXIA, 677 

Ammonia, injected intravenously into leg 

to stimulate heart and respiration, 90 
Artificial respiration, Schafer's method, 

677; Sylvester's method, 678 
Electricity, only to be used as a peripheral 

irritant to restore respiration, 681 
Laborde's lingual traction of great value, 

681 
Oxygen inhalations, 419 
Rules regarding position of patient, 679 

ASTHENOPIA, 681 

Cannabis indica, in retinal asthenopia, pre- 
scriptions for, 176 

Eserine or pilocarpine, weak solution, as a 
stimulant to ciliary muscles, 681 

Glasses, combined with prisms if necessary, 
to correct optical defects, 681 

Hot compresses, 681 

Massage, rest, salt baths, strychnine, and 
iron, if due to neurasthenia, 682 



Strychnine or tincture of nux vomica in 
large doses to stimulate ciliary muscles. 
681 

ASTHMA, 682 

Aconite, in early stages, 73 

Adrenalin, 501, 682 

Amyl nitrite, m 3 to 6 (0.2-0.4), on hand- 
kerchief, inhaled with care, relieves 
spasm, 98, 683, 684 

Antidiphtheritic serum a dangerous rem- 
edy, 685 

Arsenic, internally or smoked in cigarettes, 
best remedy when mucous membrane 
is at fault, 118, 685 

Belladonna, combined with morphine, very 
useful, 142, 683 

Bromide of potassium or sodium, gr. 30 
(2.0), half an hour before retiring, 685 

Bronchitis-tent, 685 

Chloral, rarely useful; if pushed, dangerous, 
190 

Chloroform, inhaled, relaxes spasm; also 
useful in form of liniment applied to 
chest, to abort, 208, 683 

Climatic treatment, 619 

Cocaine, applied to nasal cavities, if due 
to nasal disorders, 684 

Coffee, a cup of strong black, during par- 
oxysms, 163, 684 

Compressed and rarefied air, 685 

Diet and hygiene, 685 

Ethyl iodide, to increase secretions and 
prevent thickening, 280 

Euphorbia pilulifera, \ to 1 drachm (2.0- 
4.0) of the fluidextract, 283, 683 

GeJsemium, 291 

Grindelia, fluidextract of, TTL 10 to 30 (0.6- 
2.0), or leaves soaked in nitre smoked 
as cigarettes, or fumes of burning leaves 
inhaled, exceedingly useful, 296, 685 

Iodide of potassium, useful in bronchial, 
harmful in gastric, tvpe, 318, 685 

Lobelia, tincture, m 10 (0.6) every four 
hours, if attack threatens; ia emetic dose 
if heart be strong, when spasm is present, 
354, 684, 685 

Morphine, hypodermically, gr. \ to \ (0.01- 
0.015), alone or combined with atropine, 
682 

Nitrate of potassium alone or combined 
with belladonna, in form of cigarettes or 
inhalation of fumes, often relieves, 455, 
683 

Nitroglycerin, serviceable, if bronchial 
mucous membranes are engorged, 393, 
684 

Oil of amber, 89 

Oxygen inhalations, when cyanosis is ex- 
treme, 685 

Phylacogens, sometimes do great good, 685 

Physostigma, in bronchial asthma, to aid 
in expelling mucus, 439 

Sandalwood oil, useful in catarrhal cases, 
471 

Tobacco-smoking, often efficacious in 
patients not accustomed to it, 684 

Zinc oxide, prescription for, 533 



ATONY. 

Arsenic, in gastric and intestinal atony, 
115, 119 



INDEX OF DISEASES AND REMEDIES. 



979 



Calumba, valuable in gastrointestinal 

atony, following fevers, 167 
Capsicum, one of the best remedies in gas- 
tric atony due to debility and alcoholism, 

81, 179 
Cardamom, with bitter tonics and mineral 

acid, in gastrointestinal atony, 182 
Hydrastis, indicated in atony of mucous 

membranes, 305 
Leptandra, in duodenal atony, 351 
Mustard in gastric atony of drunkards, 

384 
Pepper, in atony of genito-urinary mucous 

membranes, 424 
Physostigma, in intestinal and vesical 

atony, 438 
Pituitrin used in atony of bladder, 448 
Pituitrin used by some in sexual atony of 

adults, 44S 
Strychnine, in intestinal atony, 402, 403 

AURAL VERTIGO. 

Pilocarpine, 443 



BALANITIS AND BALANOPOSTHITIS. 

791 

Astringent solutions, to cleanse parts, zinc 
chloride (gr. 4 to the ounce ([0.25-30.0]), 
boric acid (1 per cent.), phenol (1.5 per 
cent.) ; silver nitrate (gr. 1 to the ounce 
([0.06-30.0]) especially valuable, 791 

Lead-water, dilute, as a wet dressing, pre- 
ceded by astringent washes, in phimosis; 
if inflammation increases, circumcise, 792 

Silver-nitrate stick, touched to ulcerations, 
791 

Tannin or zinc oxide, as a dusting-powder, 
after retracting prepuce and cleansing 
over absorbent cotton, 791 



BALDNESS. (See Alopecia.) 



BED-SORES, 086 

Aloes, glycerole of, as local application, 86 

Alum, with spirit of camphor and white 
of egg, locally applied, to prevent, 686 

Gambir, with lead subacetate, locally 
applied, to harden skin, 686 

Glycerin, application daily after washing 
and rubbing part, to prevent, 295 

Incision, followed by irrigation, if sores 
tend to burrow, 686 

Iron, tincture of chloride, TU 20 (1.3) every 
four hours, as a tonic, 687 

Nitrate of silver (gr. 20 to the ounce [1.3: 
30.0]), painted over threatening part, to 
abort. If ulcers form and are sluggish, 
same solution may be used, 389. 686 

Salt and whiskey, rubbed over skin to har- 
den it (2 drachms to the pint [8.0 : 480.0]), 
686 

Scarlet red, 475 

Soap plaster, applied to sore after washing 
with bichloride solution (1:5000) and 
dusting with iodoform, 481, 6S6 

Supportive measures and an increased 
amount of food, if sloughs are large, 686 

Zinc ointment, on squares of lint, sometimes 
used in lieu of soap plaster, 686. 



BILIOUSNESS, 687 

Aconite, antagonizes the poisoning alka- 
loids, which cause slow pulse, high arter- 
ial tension, etc., 689 

Ammonium chloride, gr. 5 (0.3) thrice daily, 
if associated with catarrh, 690 

Bromides and chloral, if nervousness and 
irritation are present, 689 

Calomel, gr. £ (0.01) in powder every fif- 
teen minutes until six are taken, followed 
in four hours by a saline, if stools be 
light, 367, 374, 688 

Chirata, extract of, gr. 5 (0.3), in hepatic 
torpor, prescription for, 689 

Diet, 689 

Euonymus, extract of, gr. 3 (0.2), 689 

Horseback riding combined with gymnastic 
movements especially valuable, 689 

Leptandra, when liver is torpid, 351 

Mustard plaster or cup to nape of neck, if 
face is flushed; foot-bath also of service, 
690 

Nitro-muriatic acid, Tfl. 3 (0.2) thrice daily 
in water, of great service, 394, 689 

Podophyllin, gr. | (0.01), if stools be dark 
688 

Protoiodide of mercury, gr. ^ to J G (0.001- 
0.0015), in trituration, thrice daily, if due 

^ to catarrh, 690 

Salines, if attack is sudden, to sweep out 
poisonous matter, 688 

Salol (phenyl salicylate) or aspirin, in 10- 
gr. (0.6) doses, useful as an intestinal 
antiseptic, 690 

Stillingia, fluidextract of, dose, 20 droos 
(1.3), 6S9 



BLEPHARITIS, 690 

Boric-acid lotion, when there is accompany- 
ing conjunctivitis, 690 

Chloral, 5 per cent, solution to remove 
scabs and crusts, 690 

Creolin, 1 to 2 per cent, solution, use as a 
wash, 245 

Methyl blue, 380 

Ointments, dilute citrine, Pagenstecher's 
ointment (yellow oxide of mercury, 1 gr. 
[0.06]), vaseline, 1 drachm (4.0) ~ pyro- 
gallic acid, milk of sulphur (3 per cent.), 
locally applied after removal of crusts, 
690 

Silver nitrate, touched to crater-like ab- 
scesses, gives good results, 690 

Sodium bicarbonate or biborate solution, 
gr. 8 to ounce (0.5:30.0), to remove 
scabs and crusts, 690 

Zinc sulphate in 1 per cent, solution when 
due to Morax-Axenfeld bacillus, 690 



BOILS, 690 

Aluminum acetate useful, 88 

Belladonna, locally applied to relieve pain 
and inflammation, 691 

Calcium sulphurate, hastens pointing and 
prevents formation of new ones; useless 
in boils of diabetes, 170, 691 

Camphorated alcohol, applied over boils in 
formative stage, then wiped dry, fol- 
lowed by camphorated oil to abort, 172, 
691 



980 



INDEX OF DISEASES AND REMEDIES. 



Chloride of calcium, added to poultice, 
hastens maturation, 165 

Collodion, painted over inflamed spot, to 
abort, 238; if pus forms it may be ab- 
sorbed, if not, evacuate by incision, 691 

Egg-shells baked and eaten, for successive 
crops, 171 

Opium, locally applied to relieve pain and 
inflammation, 691 

Phenol, 5 per cent, strength, injected into 
apex of boil when formation is assured, 
to abort, 432, 691 

Phosphorus, 437 

Poultices, containing sweet oil and lauda- 
num, to assist maturation, 691 

Prescription for ointment, 691 

Silver nitrate (gr. 20 to the ounce [1.3 : 
30.0]), painted over part, may abort, 389, 
691 

Sodium citrate solution, 1 per cent., on lint 
or gauze, to cause slough to come away, 
691 

Staphylococcic vaccine, 691 

BONE DISEASE. 

Calcium chloride, in deficient bone forma- 
tion, 165 

Iodide of iron, syrup of, if ansemia exists, 
322 

Iodine ointment, diluted one-half, or tinc- 
ture, locally applied, 322 

BREASTS (INFLAMED), 692 

Aconite or veratrum, to depress circulation, 
692 

Belladonna, internally or as an ointment, 
before and after inflammation, with cold 
compresses to breast, 141, 692 

Breast-pump, if milk continues to form, 692 

Incise as soon as pus forms, 692 

Lead-water and laudanum, when connec- 
tive tissue is involved. 692 

Pressure bandage with ice-bag, 692 

Purges, mild saline, 692 

BREATH, FETID. 

Camphor, as mouth- wash, 172 

BROMIDROSIS. 

Belladonna, 141 

Borax of great value, 149 

Carbonate of calcium, precipitated, a useful 

application, 164 
Creolin ointment useful, 245 
Formaldehyde useful. 287 
Lead plaster and linseed oil, equal parts, 

applied every third day, 350 
Salicylic acid, used as a dusting-powder, 

prescription for, 467 



BRONCHITIS, 692 

Aconite, alone or combined with sweet 

spirit of nitre, in initial stage, 73, 693 
Amber, oil of, and olive oil (1 : 3), applied 

to back and front of chest, in infantile 

bronchitis, 89 
Ammoniac, useful in old forms devoid of 

inflammation, 91 



Ammonium carbonate, alone or with the 
chloride, especially useful in children; 
gr. 2 to 10 (0.12-0.6) in syrup of acacia, 
94 

Ammonium chloride, in second stage to 
stimulate bronchial tubes, prescription 
for, 94, 602, 696 

Apomorphine, 111 

Asafcetida, as a stimulating expectorant, 
133 

Belladonna, to check excessive secretion 
and stimulate respiration, 696 

Benzoic acid, 146 

Bronchitis-tent, 694, 695 

Caffeine, or strong coffee, to stimulate res- 
piration if suffocation threatens, 697 

Camphor, in old or atonic cases, 172, lini- 
ment rubbed on chest, 693 

Cimicifuga in chronic bronchitis, 214 

Climatic treatment in chronic bronchitis, 
619 

Codeine, recommended when cough is 
excessive, 233, 697 

Creosote, recommended in chronic bron- 
chitis, 246, 602 

Croton oil and sweet oil (half and half), 
sometimes applied to chest, 249 

Cubebs or copaiba, as expectorants, liable 
to derange stomach, 242, 249, 697 

Digitalis, if heart be feeble, 697 

Dover's powder, gr. 5 to 10 (0.3-0.6), with 
a hot drink, useful in early stage, 693 

Dry cups, if secretion is excessive, 698 

Ethyl iodide, 5 to 10 minims (0.3-0.6), 
inhaled from a handkerchief every few 
hours in the later stages to loosen secre- 
tions, 280, 605, 696 

Eucalyptus oil, valuable in later stages, 
dose gtt. 1 to 5 (0.06-0.3), in capsule, 
every three hours, 282, 697 

Euphorbia pilulifera, \ to 1 drachm (2.0- 
4.0) of fluidextract, in chronic bronchitis, 
283 

Flaxseed tea, a useful demulcent, 285 

Gallic acid for profuse expectoration, 288 

Grindelia, very useful in later stages, 296 

Guaiacol vapor inhalations very valuable, 
297 

Hot foot-bath, with drinks of hot lemonade 
in early stages, 693 

Inhalations of steam from boiling water, to 
relieve bronchial soreness when counter- 
irritation fails, 602, 603, 604 

Iodide of potassium, often useful when 
ammonium salts fail, contraindicated if 
secretion is excessive, 318 

Iodine externally, 322 

Iodoform, to lessen cough and fetid dis- 
charge, 327 

Ipecac, to unload stomach, 329; as a seda- 
tive expectorant, 330 

Mustard plasters, 383, 693, 698 

Myrrh with expectorant mixtures, useful 
in later stages, 385 

Oronasal respirator with terebene, iodide 
of ethyl, and chloroform, 696 

Oxygen, inhalations, when dyspnoea is 
great, 419, 697 

Pitch, useful externally in chronic bron- 
chitis, 446 

Potassium citrate, with ipecac to aid for- 
mation of secretion, prescriptions, 453, 
693 

Potassium cyanide for excessive cough, 454 



INDEX OF DISEASES AND REMEDIES. 



981 



Resin, inhalation of fumes, 458 

Sandalwood oil, in later stages, dose, 5 to 
10 minims, 471, 697 

Sanguinaria, 472 

Senega, a stimulating expectorant, in sub- 
acute and chronic stages, 478 

Squill, inferior to other drugs as an expec- 
torant, 489 

Steam inhalations, 603, 693 

Strychnine, to stimulate respiration, if 
suffocation threatens, 403, 697, 698 

Tar, 506 

Tartar emetic, as an expectorant, gr. -fa 
(0.C01) hourly, or 1 drachm (4.0) of solu- 
tion (gr. | [0.031 to 4 ounces [120 C.c.l), 
or as an emetic in sthenic cases, 101 

Terebene, if ammonium chloride fails, 
dose, 5 to 10 minims (0.3-0.6), in cap- 
sule or emulsion; must be stopped if 
kidneys or stomach are irritated; or vised 
in an inhaler with equal parts of iodide 
of ethyl and chloroform, 507, 696 

Terpine hydrate or terpinol useful, 508. 697 

Thiocol in chronic bronchitis, 509 

Turpentine inhalations or applied to chest, 
for children diluted one-half with sweet 
oil, 525 

Turpentine stupes, as counterirritants, 698 

Water, hot and cold dashes, if death is 
imminent from suffocation, 697 

BRONCHOCELE. 

Iodine efficient, 321 

Ointment of biniodide of mercury, useful 

in, 371 
Potassium iodide internally, and tincture 

of iodine externally, 318 
Thymus gland in, 513 



BRONCHORRH(EA. 

Alum, solution, gr. 20 to the ounce (1.3 

30.C), applied in fine spray, 87 
Gallic acid, 288 
Strychnine, 403 



BRUISES. 

Alcohol, as a lotion, very useful, 79 

Arnica, 113 

Liquor plumbi subacetatis, locally applied, 
strength 1 to 4 ounces to the pint (30.0- 
120.0 : 480.0) ; contraindicated, if skin 
is broken; also useful as lead-water and 
laudanum (water 16, lead-water 4, lauda- 
num 1), 350, 414 

Warming plaster, 446 

BUBO. 

Incision, at first sign of suppuration, fol- 
lowed by washing with either bichloride 
solution (1 : 1000), hydrogen peroxide 
(| strength), or zinc chloride (gr. 40 to 
the ounce [2.6 : 30.0]), 702 

Iodine, painted around spot, with compress 
and spica bandage, or hot bag over 
swelling, 702 

Phenol solution (gr. 8 to the ounce [0.5 : 
30.0]), 10-minim injections, preceded by 
ether spray, 432 



BURNS ' AND SCALDS, 698 

Adrenalin chloride, drachm 1 (4.0) of a 
1 : 1000 solution, in a pint of normal salt 
solution intravenously as a stimulant, 
698 

Ambrine, 699 

Bath in the treatment of, 698 

Bismuth hydroxide, 148 

Boric acid solution, a useful dressing, 150 

Calcium carbonate, precipitated, as a dres- 
sing, 165 

Camphor and phenol mixture useful, 172 

Carron oil in, 169, 286 

Castor oil, with a few drops of balsam of 
Peru or oil of eucalyptus, excellent, 184 

Chloretone in 10 per cent, ointment, 193 

Cold cream, as a dressing, 462 

Digitalis, in shock, if circulation fails to 
respond to less powerful stimulants, 698 

Glutol, as a dressing, 288 

Hypodermoclysis useful, 595, .698 

Ichthyol ointment, 315 

Lead carbonate, as an ointment or, with 
linseed or other oils, as a dressing, 349 

Lime-water and linseed oil, equal parts, is 
a standard application, 169, 285 

Morphine and atropine' gr. \ to h (0.015- 
0.03) of former to gr. T fo (0.0006) of 
latter, to allay pain, 698 

Opium useful, 414 

Orthoform, as an antiseptic and anaesthetic, 
418 

Phenolized sweet oil, cosmoline, or simple 
cerate, useful application to counter- 
irritation burns, 431, 432 

Picric acid the best dressing, 439, 699 

Potassium citrate with sweet spirit of nitre, 
if urine is high colored, 700 

Prescription for, 699 

Salicylic acid, prescription for, 467 

Scarlet red useful in slowly healing burns, 
475 

Stimulants, if shock is severe, 698 

Zinc oxide, 532 

CANCER (GASTRIC). 

Arsenic, small doses often repeated, to 
relieve vomiting, and pain in gastric 
cancer, 118 

Condurango, in the dose of 1 drachm (4.0) 
of the fiuidextract, 240 

Dionin as substitute for morphine, 260 

Hydrochloric acid, 307 

Lavage in, 610 

CANCRUM ORIS. 

Arsenic internally, 118 

Boric acid as a mouth-wash, 149 

CARBUNCLE. 

Aluminum acetate useful, 88 

Phenol solution (gr. 8 to the o\mce [0.5 : 

30 01), hypodermic injections, to abort, 

432 
Phosphorus, 437 

CARIES. 

Lime salts, especially valuable in dental 
caries of nursing women, 167 



982 



INDEX OF DISEASES AND REMEDIES. 



CATARRH (DUODENAL). 

Salol of greatest use, 470 

CATARRH OF AIR-PASSAGES. (See 
Nasal Catarrh.) 

Alum solution (gr. 20 to the ounce [1.3 : 

30.0]), applied in fine spray, 87 
Apomorphine, in subacute and chronic 

forms of, 111 
Arsenic, internally, 118 
Camphor of service in old and atonic cases, 

172 
Ethyl iodide, by inhalation in subacute or 

chronic catarrh, 280 
Sozoiodol, applied locally in 5 per cent. 

solution, 487 

CATARRH OF BLADDER. 

Ammonium benzoate, to render urine acid, 

92 
Juniper, a valuable stimulant, in chronic 

cases, 341 

CATARRH (INTESTINAL). 

Ammonium chloride, useful in subacute 

types, 95 
Chlorate of potassium, injections (gr. 20 to 

the ounce [1.3 : 30.0]), in acute rectal 

catarrh, 453 
Iodide of potassium, if ammonium chloride 

fails to relieve, 318 
Leptandra, fmidextract, dose, 20 minims 

to 1 drachm (1.3-4.0), 350 
Salol, 470 

CATARRH (RECTAL). 

Potassium chlorate, 20 gr. to the ounce of 
water, will often produce a cure after 
one or two injections, 453 

CATARRH OF UTERUS. 

Hydrastis, 305 

Sozoiodol, in powder, applied by tampon, 
in catarrh of cervix uteri, 487 

CEREBRAL DISEASES. 

Blisters, to nape of neck in cerebritis, 576 
Croton oil, in cerebral congestion, 249 
Elaterium, in cerebral congestion, 262 
Jalap may be used to deplete in cerebral 

congestion, 339 
Phosphorus, often of service in cerebral 

softening, 437 

CHANCRE. 

Nitric acid, used as a caustic, surrounding 

tissues being protected by oil, 391 
Salicylic acid, in soft chancres, 468 

CHANCROID, 700 

Acetanilid, used in a dry powder, 67 
Actual cautery, the most destructive caus- 
tic, 700, 701, 702 
Bismuth and zinc oxide, or calomel and 
bismuth are substitutes for iodoform 701 



Cocaine, 20 per cent, solution, to relieve 
pain of cauterization, 700 

Hot sitz-bath or general warm bath, 618, 
702 

Iodoform, the best dusting-powder after 
cauterizing, also useful as a palliative 
treatment, preceded by nitric acid was 
(5J to water Oj [4.0 : 480.0]), in erosive 
chancroid, 701 

Iodol or aristol, as a substitute for iodo- 
form, 701 

Nitric acid, a good caustic, surrounding 
tissues being protected by oil, 391, 700 

Salicylic acid in powder or ointment, 468 

CHAPPING. 

Bismuth subnitrate, prescription for, 148 

Boric acid, prescription for, 150 

Calcium carbonate, precipitated, as a local 
protective in intertrigo of infants, 164 

Camphor, added to precipitated calcium 
carbonate, useful in intertrigo, 172 

Carbonate of zinc in infantile forms, pre- 
scription for, 531 

Cold cream, a useful application, 462 

Light magnesia, as a dusting-powder in 
intertrigo, 355 

Lycopodium, as a dusting-powder, 355 

Starch, as a dusting-powder in intertrigo, 
490 

Zinc oxide, in powder form, useful in inter- 
trigo, 533 

CHILBLAINS. 

Alum, as a wash, 87 

Capsicum, tincture, painted over parts or 

applied as a paper, prescription for, 180 
Ceratum resinae, 458 
Ichthyol ointment, 315 
Iodine ointment and lard, equal parts, 

give great relief, 323 

CHLOASMA OF PREGNANCY. 

Zinc oxide, prescription for, 532 

CHLOROSIS. (See Anemia.) 

CHOLERA (ASIATIC), 702 

Atropine and strychnine are useful. 704 

Camphor, in the form of camphorated wine, 
of the greatest service in controlling 
cramps, 703 

Enteroclysis, associated with hot baths, 
very valuable, 582 

Ether, subcutaneously, as a diffusible stim- 
ulant, 704 

Hypodermoclysis, very useful, 596, 704 

Intravenous saline injections, 609 

Opium, 703 

Phenyl salicylate and aspirin, 470, 704 

Potassium permanganate, in keratin- coated 
pills, probably even more useful than 
camphor, 704 

Purgatives, contraindicated unless bad 
food has been taken, 703 

Quarantine and strict hygiene, as pro- 
phylactic, 702, 703 

Salol, one of the best remedies, 470, 704 

Sulphuric acid with camphor to control 
diarrhoea, 499, 703 

Transfusion, 630 



INDEX OF DISEASES AND REMEDIES. 



983 



CHOLERA INFANTUM, 705 

Arsenic, to check vomiting, prescription 
for, 707 

Atropine as a vasomotor stimulant, 705 

Beef-juice, as a food, especially valuable, 
705, 706 

Brandy, a drop or two with each teaspoon- 
ful of food, 705 

Buttermilk, diluted with water, when milk 
feeding is bemin again, but is contraindi- 
cated if stools are acid in reaction, 706 

Castor oil, with paregoric, to empty bowels 
and allav irritation, 705 

Diet, 705, 706 

Enteroclysis, very valuable, 708 

Hypodermoclysis, or Murphy drip for col- 
lapse, 70S 

Iodoform and oil injections to relieve tenes- 
mus, 327 

Irrigation of bowels, 708 

Lactic acid bacillus, Bulgarian, in tablets, 
useful, 707 

Laudanum, 1U 10 (0.6), and starch-water, 
oz. 2 (60.0), by enema, and calomel, gr. 
i*2 (0.005), or gray powder, gr. I (0.01), 
by mouth, to control vomiting and purg- 
ing, if severe, 707 

Levulose or glucose, by bowel or intraven- 
ously, if patient is stuporous, 708 

Milk to be avoided at first, 706 

Mustard or spice plaster, over belly, always 
useful, 708 

Podophyllin, if stools are of peculiar pasty 
white color. 706 

Prescriptions for, 707 

CHOLERA MORBUS, 708 

Camphor, 171 

Castor oil, with laudanum, to sweep out 
intestines, before diarrhoea mixture is 
used, 708 

Ipecac, gr. 3 (0.2) every two hours, often 
of service, 330 

Morphine and atropine, if pain is severe, 
709 

Mustard or capsicum plaster, over abdo- 
men, 708 

Prescription for, 709 

Salol (phenyl salicylate), prescription for, 
470 

CHORDEE, 788 

Aconite, often relieves, 73 

Belladonna internally, and ointment ap- 
plied to under surface of penis, 142 

Bromide of potassium, drachm 1 (4.0), 
with chloral, gr. 10 (0.6), at bedtime, 
repeated during night if necessary, 788 

Camphor with bromides, very useful in 
some cases, 172 

Cantharides, 1U 1 (0.06) thrice daily. 178 

Hot sitz-bath and steeping penis in hot 
water before retiring, relieves, 586 

Morphine, gr. \ (0.015), with atropine, pr. 
fa (0.001), hypodermically near peri- 
neum, to relieve, 788 

Opium or belladonna suppositories, to 
relieve, 788 

CHOREA, 709 

Arsenic, in ascending doses; discontinued if 
symptoms of poisoning ensue, 115, 709 



Bromide of iron, in anaemia of, 334 

Bromides with chloral, when there is in- 
somnia, prescription for, 710 

Chloral, 190 

Chloroform inhalations when excessive, 203 

Cimicifuga alone, or with arsenic, very 
useful, 213, 709 

Hot (lack, at bedtime, if muscular jerkings 
are severe, 593, 710 

Monobromated camphor, 174 

Nitroglycerin, 393 

Novaspirin, 709 

Parathyroid gland, 423 

Salicylates of value, if associated with rheu- 
matism, 709 

Silver nitrate, occasionally used, not 
reliable, 388 

CHOROIDITIS, 710 

Mercury, iodides and alteratives usually 

indicated, 710 
Tuberculin in suitable cases, 710 



CINCHONISM. 

Potassium bromide, as a preventive, 155 

CIRRHOSIS OF LIVER. 

(See Hrpatic Cirrhosis.) 

COLDS. (See Coryza.) 

COLIC. 

Asafcetida, useful in children, 133 

Chloral and bromide, when severe in chil- 
dren; prescription for, 190 

Chloroform useful in renal or hepatic colic, 
207 

Ether internally, very useful, 275 

Hoffmann's anodyne, 302 

Hyoscyamus, 311 

Matricaria, infusion, to prevent, in teeth- 
ing children, 360 

Mustard plaster, J to h strength, if skin is 
tender^ 383 

Peppermint in infantile colic, 424 

Rue, as a carminative, 462 

COLIC (HEPATIC), 710 

Belladonna, in full doses, to relax spasm, 
141, 142 

Benzoate of sodium, 712 

Calomel, if liver be very torpid, 712 

Chloroform or ether inhalations to relieve 
pain during spasm, 207, 711 

Diet, 712 

Horseback riding, 712 

Hot applications over liver as a relaxant, 
711, 713 

Morphine, gr. | to | (0.015-0.03), with 
atropine, gr. xhs (00006), hypodermic- 
ally, to relieve pain, 412, 710 

Olive or cottonseed oil, 1^ pints (720.0) 
during attack; ether, drachm 1 (4.0), 
may be added with advantage, 711 

Opium with belladonna to relieve pain 
and spasm, 412 

Salicylate of sodium, 711 

Turpentine, useful in, 713 



984 



INDEX OF DISEASES AND REMEDIES. 



COLIC (LEAD). 

Alum with morphine to allay pain, 87 

COLIC (RENAL). 

Belladonna, in full dose, 142 
Chloroform, a few inhalations often relieve, 

207 
Opium with belladonna relieves spasm and 

pain, 412 

COLLAPSE. 

Adrenalin intravenously, 501 

Belladonna, as a vasomotor stimulant, 142, 
143 

Digitalis, 256 

Ether, by mouth, inhalation, or hypoder- 
mically, of great service, 275 

Hoffmann's anodyne in sudden collapse in 
infants, 302 

Hypodermoclysis in collapse of cholera, 596 

Pituitrin as a useful circulatory stimulant, 
448 

CONDYLOMATA. 

Calomal, as a dusting-powder, often re- 
moves, 374 

CONGESTION. 

Croton oil, as a revulsive in cerebral con- 
gestion, 249 

Cupping, 578 

Digitalis, relieves stasis of congested lung 
in typhoid state, and congestion of the 
kidneys, 256 

Elaterium, in cerebral congestion, 262 

Ergot of service, especiallv with digitalis, 
264 

Glycerin, on cotton tampon, as a depletant 
in uterine congestion, 294 

Jalap, useful in plethora with cerebral con- 
gestion, 339 

Juniper often relieves congested kidneys, 
341 

Mustard, to nape of neck in cerebral con- 
gestion, 383 

Mustard hot pack often useful in internal 
congestions, 592 

CONJUNCTIVA (BURNS OF), 714 

Atjj.©pkie incorporated with liquid vaseline 
instffied into eye, to prevent iritis, 714 

Goldbeaters' skin inserted between lids 
and eyeball, or breaking up granulation 
prevents corneal inflammation, 714 

Neutralization of foreign matter, if acid or 
alkaline, 714 

Sweet oil instilled into eye after removal 
of foreign matter, 714 

CONJUNCTIVA (CHEMOSIS OF), 719 

Astringent washes, especially alum, 719 
Nicking swollen tissue with scissors, 719 
Warm, moist compresses, 719 

CONJUNCTIVA (HEMORRHAGE 
BENEATH), 719 

Boric acid or cocaine wash, when conjunc- 
tival irritation exists, 719 

Massage of globe through closed lids, to 
aid absorption of blood, 719 



CONJUNCTIVITIS (CHRONIC), 717 

Acetate of zinc, gr. 1 to 2 (0.06-0.12) to the 
ounces (30.0), 531 

Boric acid wash (gr. 10 to the ounce [0.6 : 
30.01), holocain, gr. 4 (0.24), may be 
added if there is no corneal ulcer; for 
this condition salt, gr. 4 to the ounce 
(0.25 : 30.0), may be substituted, 717 

Copper crystal, or a solution (gr. 1 to 3 to 
the ounce [0.06-0.2 : 30.0]), applied to 
diseased spot, if subacute, 244 

Correction of any refractive error, 717 

Lapis divinus, 717 

Tannin and glycerin (gr. 10 to the ounce 
[0.6 : 30.0]), as an application, 717 

Yellow oxide salve, or alum crystal, useful 
application, 377, 379, 717 

Zinc oxide in powder, or the sulphate in 
the form of a wash, 533, 717 



CONJUNCTIVITIS (DIPHTHERITIC), 

719 

Antitoxin injections the best treatment, 719 
Atropine, instilled, 719 

Boric acid or bichloride sohitions, fre- 
quently applied in early stages, 719 



CONJUNCTIVITIS (FOLLICULAR), 717 

Astringent and antiseptic lotions, 718 
Copper sulphate, as an ointment (gr. \ to 
the drachm [0 03 : 4.0]), 244, 718 

CONJUNCTIVITIS (GRANULAR), 718 

Adrenalin locally, 501 

Boric acid solution, as a wash in acute 

forms, 718 
Boroglyceride (20 to 50 per cent.), applied 

to chronic granulations, 718 
Copper citrate (5 per cent, ointment) is of 

service, 718 
Copper sulphate, crystal, applied to chronic 

granulations, 244, 718 
Corrosive sublimate solution (1 : 8000) or 

cyanide of mercury (1 : 5000) and nitrate 

of silver, argyrol, or protargol may be 

employed to check purulent discharge, 

718 
Crushing granulations, often satisfactory, 

719 
Electrolysis, 719 

Excision of the fornix conjunctiva, 719 
Glycerole of tannin, applied to chronic 

granulations, 718 
Jequirity infusion (3 per cent.) painted on 

inner side of eyelids, of use, 340 
Leeches to temple, to reduce inflammation 

in acute stage, 614 
Phenol, hydrastin, iodide of silver, ich- 

thargon, 2 to 3 per cent, and ichthyol, 

have been employed, 718 
Scarification, not advisable, 719 
Silver nitrate, stick or solution (gr. 10 to 

the ounce [0.6 : 30.0]), applied daily, if 

there is discharge; neutralize excess with 

salt solution, 390, 718 
Yellow oxide of mercury ointment with 

lard, equal parts, in chronic types, 377 
X-rays and radium recommended by some, 

719 



INDEX OF DISEASES AND REMEDIES. 



985 



CONJUNCTIVITIS (LACHRYMAL). 

Treatment same as for chronic type. 

CONJUNCTIVITIS (MUCOPURULENT) . 

Treatment same as for purulent type. 

CONJUNCTIVITIS (PURULENT), 715 

Argyrol and protargol as substitutes for 
silver nitrate, 112, 715 

Atropine if corneal ulcer appears, 716 

Creolin solution, 1 per cent., 245 

Glycerite of boroglycerin, 295 

Iced compress in early stage, to reduce 
inflammation, 715 

Leeching, useful if inflammation is high, 
contraindicated in infants. 614 

Permanganate of potassium, aqua chlorini, 
argentamin, protargol, sulphocarbolic acid 
solution, alum sulphate, zinc sulphate, 
creolin (1 per cent.), or iodoform oint- 
ment may be tried, 716 

Silver nitrate, stick or solution (gr. 10 to 
the ounce [0.6 : 30.0]), touched to lids 
after they have been cleansed of pus, 
excess neutralized with salt solution; 2 
per cent, solution dropped in newborn 
infant's eyes to prevent, 390, 715, 716 

Silvol, 25 per cent, solution, may be used, 
481 

Sozoiodol (2 : 30), 487 

CONJUNCTIVITIS (SIMPLE), 713 

Alum crystal applied when it tends to 
become chronic, 714 

Argyrol, 10 to 25 per cent, solution, in place 
of silver nitrate, 713 

Atropine usually unnecessary unless corneal 
ulcer is present, 714 

Boric acid lotion (gr. 10 to the ounce [0.6 : 
30.0]), 150, 713 

Compresses of ice to allay inflammation, 
714 

Mercury bichloride solution (1 : 10,000), if 
discharge is great, 713 

Methyl blue, 380 

Poultices and bandages contraindicated, 
714 

Protargol, 1 to 5 per cent, solution, 456, 713 

Protargol .and argyrol, 20 to 25 per cent, 
solution, in place of silver nitrate, 713 

Silver nitrate, solution (gr. 2 to 5 to the 
ounce [0.12-0.3 : 30.0]), if there is muco- 
purulent discharge. If discharge is exces- 
sive, employ gr. 10 to the ounce (0.6 : 
30.0), and neutralize excess with salt 
solution or wash with tepid water, 713 

Smoked glasses, 714 

Sodium biborate, gr. 4 to 8 to the ounce 
(0.25-0.5 : 30.0), 714 

Tannin and glycerin (gr. 10 to the ounce 
[0.6 : 30.0]), or alum crystal if there is a 
chronic tendency, 714 

Zinc oxide, 533 

Zinc sulphate solution (gr. 1 to 2 to the 
ounce [0.06-0.12 : 30.0]), alone or with 
boric acid, if there is chronic tendency, 
533, 714 

CONSTIPATION, 728 

Abdominal supporting belt in constipation 



uuuiuinai suppui iin^ ucii 111 

with enteroptosis, 720, 724 



Agar, when the stools are dry, 75, 721 
Aloes, 86; and podophyllin, with other 

drugs, useful for temporary use; pre- 
scription for, 723 
Belladonna, 142 
Bryonia, when intestinal secretions are 

deficient, 159 
Calomel, 372 
Cascara sagrada, the best curative agent, 

dose TTl 10 to 40 (0.6-2.6) of fluidextract, 

or drachm 1 (4.0) to 6 (24.0) of cordial, 

182, 722, 723 
Castor oil ultimately harmful in all cases, 

184, 722 
Colocynth, jalap, or senna, not to be used 

constantly, 722 
Compound cathartic pill, sometimes neces- 
sary, 723 
Diet of extreme importance, 721, 722 
Enemata, as a routine treatment, harmful, 

724 
Glycerin, suppositories or enemata, often 

used, 294, 724 
Gymnastic movements, horseback riding, 

or massage, with regulated diet, 721 
Hunyadi, Pluto, or Abilena waters, when 

plethora exists, 722 
Leptandra in intestinal atony, 351 
Liquid petrolatum when stools are dry, 

721 
Lobelia, in combination with cascara 

sagrada, useful in atonic forms, 354 
Magnesium sulphate by the mouth or by 

enema, 357, 722 
Manna, as a laxative fruit for adults, or 

drachms 1 to 2 (4.0-8.0) to bottle of 

milk, for infants, 359 
Mercury, as an habitual purgative, harm- 
ful, 365, 372, 722 
Opium in reflex constipation, 413, 724 
Phenolphthalein, 1 to 2 grains (0.06-0.12), 

an excellent laxative in habitual consti- 
pation, 433, 723 
Phosphate of sodium, useful in rickety 

children, gr. 5 to 10 (0.3-0.6) ; or adults, 

485, 723 
Pilula cathartica vegetabilis, may be 

required, 723 
Rhubarb, usually harmful in some cases, 

in children, useful, 460, 722 
Salines, simply to unload bowels, 722 
Seidlitz powder, 478 

Senna, said to be useful in constipation of 
. pregnancy, particularly if combined with 

cascara sagrada, 479 
Soap suppositories, useful in children, 481 
Stillingia, recommended when habitual; 

prescriptions for, 490 
Sulphur, especially valuable if hemorrhoids 

are present, 497 
Tobacco, sometimes used, 724 

CONVULSIONS. 

Allium, as a poultice, over spine or feet in 
infantile spinal or cerebral convulsions, 
83 

Amyl nitrite, 97 

Chloral with bromide, in infants; also use- 
ful alone in ursemic and puerperal con- 
vulsions, if no acute renal trouble exists, 
153, 190 

Chloroform, 203 

Intravenous saline injections, 609 

Spinal puncture in, 615 



986 



INDEX OF DISEASES AND REMEDIES. 



CORNEAL OPACITIES. 

Dionin, of service in opacities of recent 

origin, 849 
Massage with yellow oxide of mercury 

salve, 849 
Subconjunctival injections of physiological 

salt solution in corneal nebulae, 849 
Thiosinamine has been used, 510 

CORNS, 724 

Fowler's solution, locally applied, 119 
Salicylic acid, the best application, formula 

for, 466, 724 
Silver nitrate solution (gr. 60 to the ounce 

[4.0 : 30.0]), applied to soft corns every 

four or five days, 724 

CORYZA, 725 

Aconite, useful in early stages, 73 
Adrenalin locally to relieve engorgement, 

501, 725 
Allium, as a poultice to breast, or in emul- 
sion or boiled in milk, for children, 83 
Antipyrine in 4 per cent, solution as a 
spray, preceded by a cocaine spray, 10" 
725 
Arsenic, taken for months, often cures 

persistent colds, 115, 118 
Belladonna in, 143, 725 
Bromides useful in headache, 726 
Camphor, as a snuff, or inhalation of spirit, 
or fumes, when sneezing and lachryma- 
tion are excessive, 172 
Cocaine, a few minims of a 4 per cent, solu- 
tion dropped into nostril, followed by 
lotion (see Prescription) with atomizer, 
228, 725 
Cubebs, as a snuff during stage of secretion, 

249 
Glycerin, applied alone by brush or spray, 

often of service, 294 
Hamamelis, useful after acute stage is past 

299 
Hot mustard foot-bath with hot draught 
or Dover's powder, followed by rest in 
bed, may relieve, 726 
Inhalation of tincture of iodine, 324 
Iodide of potassium at beginning will often 

abort, 318 
Menthol, very useful, 425 
Prescription for wash, 725 
Prescriptions for nebulizer, 605, 606 
Quinine, internally, combined with chloride 
of ammonium, useful after secretion is 
established, 726 
Sodium bicarbonate, gr. 30 (2.0) every two 
hours for three doses, of much benefit, 
725 
Sweet spirit of nitre, 503, 726 
Tartar emetic, 101 
Urotropin useful to abort acute coryza, 301 

COUGH. 

Acacia, as a mucilaginous drink with flax- 
seed and liquorice, to loosen hacking 
cough, 63 

Almond, essential oil of, in emulsion, as a 
demulcent in cough of phthisis, 84 

Belladonna, the best remedy in nervous 
cough, 142 



Cannabis indica, a useful adjunct to cough 
mixtures, 175 

Chloroform, useful, added to cough mix- 
tures for irritant cough, 207 

Codeine, useful in nervous cough, 233 

Dionin, i to f gr. (0.015-0.045), to relieve 
excessive cough, 260 

Flaxseed tea, alone or with paregoric, a 
useful demulcent in excessive cough, 285 

Gelsemium in nervous cough, 291 

Heroin, 300 

Honey, 303 

Hydrocyanic acid, highly recommended, 
prescription for, 308 

Hyoscyamus in nervous cough, 311 

Hypnal, 314 

Iodine, as a paint over supraclavicular 
spaces, in irritative cough, 322 

Ipecac, in spray, useful in chronic winter 
cough, 330 

Morphine in wild-cherry syrup useful in 
irritative cough and when cough is 
greater than necessary to expel mucus, 
413 

Paregoric (1 drachm [4.0]) in hot water, 
from which the steam is inhaled, useful 
in irritative form of cough, 413 

Sandalwood oil for excessive cough follow- 
ing influenza, 471 

Syrup of wild cherry, as a vehicle for cough 
mixtures, 456 



CRAMPS. 

Belladonna, internally, or locally as a 

liniment, 141 
Chlorodyne, for stomach cramp, 193 
Ginger, especially useful in menstrual 

cramp due to cold, 292. (See Dysmenor- 

rhcea.) 

CRETINISM. 

Thyroid gland, very useful, 513 

CROUP (MEMBRANOUS). 

(See Diphtheria.) 

CROUP (SPASMODIC). 

Aconite useful, 73 

Amvl nitrite, inhalations, if paroxysm is 

severe, 98, 726 
Belladonna, bromides, chloral, or opium in 

small doses at bedtime, as a preventive, 

726 
Bromides and lactucarium, 726 
Bronchitis-tent, 726 
Cold cloth around neck, and child placed 

at once in hot bath, air of room being 

moistened by steam, 726 
Hot compress is very useful, 586 
Iron and arsenic as tonics if child is anaemic 

and rachitic. 726 
Menthol, useful, 426, 602, 727 
Prophylactic measures, 726 
Sanguinaria, as an emetic, unfavorable, 472 

CYSTITIS (ACUTE), 727 

Aconite in full dose, with sweet spirit of 
nitre and potassium, citrate if there is 
fever; prescription for, 727 

Argyrol, 10 to 25 per cent, solution, may 
be injected into the bladder, 112 



INDEX OF DISEASES AND REMEDIES. 



987 



Belladonna, alone or with aconite, espe- 
cially useful if due to cold; dose, lfl 5 
to 10 (0.3-0.6) thrice daily, 728 

Boric acid, to render urine acid, 150 

Cannabis indica, preferable to opium for 
relieving pain, 176, 727 

Copaiba, useful in subacute stage, 242 

Creolin, as a vesical wash (1 to 2 per cent, 
solution) in cystitis of women, 245 

Flaxseed tea, as a demulcent, 285 

Hot compress over bladder, should not 
contain irritants, 727 

Hot sitz-bath and enemata to relieve bear- 
ing-down pain, 727 

Hygienic measures, 727 

Laudanum, TU 30 (2.0), to starch-water oz. 
2 (60.0), in enema, to relieve bearing- 
down pain, 727 

Leeches to perineum or cups to sacrum. 727 

Liquor potassii hydroxidi, Tl\ 5 (0.3) every 
four hours, if urine is acid, 727 

Opium, belladonna, or iodoform supposi- 
tory, to allay bearing-down pain, 413, 
727 

Quinine, contraindicated, 728 

Salines, in earlv stage to evacuate bowel, 
728 

Salol (phenyl salicylate), gr. 10 (0.6) thrice 
daily, if inflammation becomes purulent, 
728 

Urotropin (hexamethylenamine) in ammo- 
niacal cystitis, 301, 728 

CYSTITIS (CHRONIC), 728 

Arbutin, gr. 3 to 5 (0.2 0.3), or fluidex- 
tract of buchu or uva ursi, \ to \\ 
drachms (2.0-6.0), to improve vesical 
mucous membrane when inflammation 
is of subacute type, 526, 729 

Benzoate of ammonium, urotropin, or boric 
acid, gr. 5 to 10 (0.3-0.6), in pill, to 
render urine acid, 92, 729 

Benzoic acid useful when urine is alkaline 
and loaded with phosphates, 145 

Buchu, 160, 729 

Cantharides, 178, 729 

Chloretone solution useful, 729 

Grindelia, as a vesical stimulant, 296 

Juniper of value, 341 

Mercurol solution, 729 

Mercury bichloride solution (1 : 10,000), as 
an injection to cleanse bladder, 729 

Myrrh, often of service, 384 

Opium suppositories, gr. \ to \ (0.015-0.03), 
very useful, 414 

Pareira, 423 

Potassium salts, except bitartrate, to ren- 
der urine alkaline when mucus is exces- 
sive, 728 

Salol (phenyl salicylate), 729 

Sandalwood oil, 471, 729 

Silver nitrate solution (gr. 1 to oz. 4 [0.06 : 
120.0], increased gradually to gr. 2 to 
oz. 1 [0.12 : 30.0]), as an injection when 
discharge is mucopurulent, followed by 
salt solution if pain is severe, 729 

Strychnine and cantharides, when vesical 
atony is great, 729 

Turpentine, oil of sandalwood, cubeb, or 
copaiba, useful when vesical atony is 
great, 729 

Urotropin or uritone, 301, 728 

Uva ursi, 526, 729 

Vaccines, 728 



DEAFNESS. 

Thiosinamine, when due to thickening of 
drum or fixation of aural bones, 510 



DEBILITY. 

Arsenic, with bitter tonics, very useful, 115 

Calomel, in debility of children, often re- 
lieves, 373 

Capsicum for gastric atony, 179 

Eupatorium, a good tonic, 283 

Lime salts, 166 

Phosphorus, of service in sexual debility, 
437 

DELIRIUM TREMENS. 

Apomorphine to produce nervous quiet, 111 
Chloral, of great service used cautiously, 

190 
Croton oil, 249 
Hops, 304 

Hyoscine, in insomnia, 313 
Monobromated camphor, when nervous 

twitching is troublesome, 174 
Valerian with morphine, frequently used, 

527 

DERMATITIS. 

Chloride of ammonium lotion, when due 
to ivy-poisoning, 95 

Grindelia robust a in solution one of the 
best lotions in ivy poisoning, 296 

Lead acetate useful in ivy-poisoning, 348 

Lead-water and laudanum in ivy-poisoning, 
349 

Lobelia infusion as a lotion in ivy-poison- 
ing, 354 

DIABETES INSIPIDUS, 730 

Arsenic, 118 

Belladonna or opium, if due to nervous 

irritability, 730 
Carbonate or citrate of lithium, gr. 10 

(0.6), with sodium arsenite, gr. -^ 

(0.002), valuable in gouty types, 353 
Ergot, in combination with bromide of 

sodium, 264, 730 
Gallic acid, alone or with opium, one of 

the best remedies, 288, 730 
Opium, 414 
Pituitrin, 448, 730 

Rhus aromatica, highly recommended, 461 
Strychnine and sulphate of iron, as tonic, 

730 

DIABETES MELLITUS, 730 

Acidulated water or non-purgative alka- 
line water, to allay thirst, 736 

Almond bread, bran bread, or artificial 
milk, as a food for diabetics, 84, 650 

Alum, 87 

Antipyrine, 107, and arsenate of sodium 
and carbonate of lithium when of gouty 
origin, 107, 734 

Carbonate of sodium by intravenous injec- 
tion in diabetic coma, 736 

Codeine, in ascending doses, beginning 
gr. 1 to 5 (0.06-0.3) thrice daily, 233, 
735 

Colchicum and iodides, in gouty types, 735 

Dextrose in solution may be given freely, 
736 



988 



INDEX OF DISEASES AND REMEDIES. 



Diet, 730, 731, 732, 733 

Ether hypodermically, to support heart 

in diabetic coma, 736 
Gallic acid, with opium, one of the best 

remedies, 288 
Glycerin or saccharin, as sweetening agents 

to replace sugar, 294, 463, 736 
Hypodermoclysis, 596, 736 
Iodol, gr. 2 to 6 (0.12-0.4) thrice daily, 

recommended, 328 
Iron, lacto-phosphates of lime and sodium, 

strychnine, and astringents, if cachexia 

comes on, 736 
Levulose, as a substitute for sugar, 351, 736 
Lime-water, 168 
Lithium carbonate or citrate, with arsenic, 

very useful, if due to gout, 353, 735 
Morphine, very useful in ascending doses, 

735 
Opium, gr. \ to \ (0.015-0.03) thrice daily, 

largely used, 414, 735 • . 
Pancreas of doubtful value in pancreatic 

diabetes, 293, 421 
Pancreatin, when the disease is due to a 

lesion of the pancreas, 421 
Purgatives, restricted diet, and exercise, if 

due to high living and sedentarv habits, 

735 
Saccharin in place of sugar in beverages, 463 
Salicylates and iodide of potassium, if due 

to rheumatic or gouty taint, 735 
Sodium bicarbonate, oz. \ to 1 (16.0-30.0) 

daily when coma is feared, because of 

increase of acetone in urine, 736 
Taka-diastase diminishes polyuria, 251 
Transfusion, in diabetic coma, 630. 736 

DIARRHCEA, 737 

Allspice, 444 
Arsenic, 119 
Belladonna, may be used in serous types, 

141 
Beta-naphthol-bismuth, in serous and fer- 
mentative types, 145 
Bichloride of mercury, gr. 2 # ff (0.0003) 

hourly, if stools be slimy and bloody, 371, 

740 
Bismuth, with phenol, gtt. 1 to 2 (0.05-0.1), 

highly recommended in serous and sum- 
mer diarrhoea, 147, 431, 739 
Cajuput, TU 10 to 20 (0.6-1.3), in serous 

forms, 164 
Calomel, followed by a saline, useful in 

sthenic cases of summer diarrhoea, 370, 

739 
Calumba, in summer and serous diarrhoeas 

prescription for, 168 
Camphor, useful in serous, but never in 

mucous types, 171, 738 
Castor oil, with laudanum and sodium 

bicarbonate, to unload bowel and render 

it alkaline, 184, 737 
Chalk mixture, with kino and gambir, in 

serous diarrhoeas, prescription for, 165 
Charcoal, useful in acid and fermentative 

types, 181 
Chirata, nitro-muriatic acid, or, better 

still, nitric acid and cardamom in 

mucous type, prescription for, 738 
Chlorate of potassium for acute rectal 

catarrh with mucous diarrhoea, 453 
Chlorodyne, largely used in serous types, 

193 



Chloroform, with astringents and opium, 
very useful after removal of irritant 
cause, 207, 738 

Cinnamon, as a stimulant in serous types, 
224 

Cloves, to prevent griping, 226 

Copper sulphate, gr. \ (0.015), with opium, 
gr. 1 (0.06), in pill, if due to ulceration, 
243 

Creolin in entero-colitis, 5 : 1000 of water, 
245 

Diet for summer diarrhoea, 737, 739 

Enteroclysis, when mucous form becomes 
chronic, 582, 741 

Ergot, sometimes useful in serous types, 
264 

Eudoxine, as an intestinal antiseptic in 
children, 282, 739 

Gallic acid, 288 

Gambir, alone or with opium, in serous 
types, prescription for, 289, 705 

Ginger, a good addition to diarrhoea mix- 
tures, 292 

Guaiacol carbonate, in fermentative forms 
of, 299 

Haematoxylon, useful in children, because 
of agreeable taste, 299 

Hope's camphor mixture, in serous and 
choleraic types, 304 

Ipecac, gr. \ to \ (0.015-0.03) thrice daily, 
useful in summer diarrhoea of children, 
330, 739 

Kino, formula for, 342, 739 

Lactic acid bacillus useful in infantile diar- 
rhoea with putrefactive changes in the 
bowel, 343 

Lead acetate, with opium and camphor 
in serous types, prescription for, 348, 738 

Mercury, with chalk or calomel, in hepatic 
disorder, 375, 739 

Morphine, gr. fa to fa (0.0008-0.0012), hy- 
podermically, often checks summer diar- 
rhoea in children, 414 

Mustard plaster or other counterirritants 
to abdomen, 737 

Naphthalene or naphthol, in fetid and sum- 
mer diarrhoea, 145, 385, 739 

Nitrate of silver and hyoscyamus, or lead 
acetate and opium, in mucous diarrhoea, 
prescription for, 737, 741 

Nitro-muriatic acid or podophyllin, gr. 
fa to fa (0.0012-0.0015), in summer 
diarrhoea, if duodenum is at fault, 395, 
738, 739 

Nutmeg, useful in serous types, 401 

Opium, 414, 738 

Pancreatin in lienteric diarrhoea, 421 

Pepsin with hydrochloric acid in summer 
diarrhoea, if gastric digestion is deficient, 
739 

Phenol, especially useful as an intestinal 
antiseptic, 431, 739 

Phenolsulphonate of zinc, 2 grains (0.12) 
every three hours, of service in summer 
diarrhoea, 433, 739 

Phosphate of sodium, lime salts, and com- 
mon salt in summer types, if rickets is 
present, 485, 739 

Podophyllin, 448, 739 

Precipitated carbonate of calcium, in 
serous diarrhoea, 164 

Raspberry-leaves, used in domestic medi- 
cine, 462 



INDEX OF DISEASES AND REMEDIES. 



989 



Rhubarb, often useful, preceding direct 

treatment in summer diarrhcea, 460 
Salol (phenyl salicylate) combined with 

chalk mixture, 470, 739 
Sulphate of iron in chronic forms, 338 
Sulphuric acid, especially valuable in 

serous types, prescription for, 499, 738 
Tannic acid, in atonic or serous types, 505 
Tar mixture, highly recommended in ob- 
stinate types, formula for, 506 
Thymol, naphthalene, and especially salic- 
ylic acid, used in intestinal antiseptics, 
in summer diarrhcea, 739 
Trimethol in infantile diarrhcea, 516 
Zinc oxide, in summer types, 533 
Zinc sulphate, 2-grain (0.12) pills, espe- 
cially useful with opium or podophyllin, 
gr. £jj (0.001), in serous types, 533 

DIARRHCEA (CHRONIC), 741 

Ammonium chloride, gr. 5 (0.3) every four 
hours, best remedy in persistent catar- 
rhal states, 742 

Arsenic, 119 

Bismuthi et ammonii citras, in chronic 
serous types, 149 

Diet, 741 

Ipecac, gr. 3 (0.2) every two hours, of 
service, 330 

Iron sulphate, gr. 5 (0.3) , in pill, in chronic 
types, 338, 742 

Nitric acid, with a bitter tonic, useful in 
green diarrhcea of children, combined 
with pepsin, 391 

Operative procedures when due to lesions 
of the rectum, 742 

Podophyllum, 448 

Potassium iodide, gr. 3 to 5 (0.2-0.3), if 
catarrhal state is obstinate, 742 

Rockbridge alum-water, useful when ana?-* 
mia is present, 618 

Silver nitrate in pill form, or in other cases 
rectal injections of this drug, gr. 2 to 
oz. 1 (0.12-30.0), followed by iodoform 
suppository, of greatest benefit, 742 

DILATATION (GASTRIC AND INTES- 
TINAL). 

Physostigma with mix vomica, 438 

DIPHTHERIA, 742 

Alum, 87 

Antistreptococcic serum, 551 

Antitoxin, of great value: 2000 to 5000 
units should be thrown into the con- 
nective tissues of the back. A special 
syringe is used for this purpose, and 
should be perfectly aseptic, 547, 743 

Borax solution, as a gargle in, 149 

Bronchitis-tent, 602, 748 

Chlorate of potassium, contraindicated for 
internal use because of danger to the 
kidneys. It may be applied upon a 
swab, 452, 748 

Hypodermoclysis, 748 

Ice-bags to the neck, ice in the mouth, and 
the tincture of the chloride of iron inter- 
nally, if glandular suppuration threatens, 
748 

Irrigation of the nasal chambers useful in, 
742 



Lime-water as spray or application very 
useful in, 169 

Loeffler's application (menthol, dr. 2\ 
[10.0], dissolved in dr. 9 [34.0] of toluol; 
add dr. 1 [4.0] of liquor ferri chloridi and 
absolute alcohol, fl. oz. 2 [60.0]), 743 

Milk diet, 748 

Monsel's solution, as a topical application, 
338 

Oxygen inhalations, strychnine, and atro- 
pine if suffocation is imminent. Intu- 
bation or tracheotomy may be necessary, 
748 

Peroxide of hydrogen is the best local ap- 
plication. May be applied on a swab or 
as a spray (1 : 4), to remove false mem- 
brane, 310, 742 

Phenol (1 : 100) in the form of spray or 
gargle, 431 

Potassium permanganate solution (gr. 20 
to the pint [1.3 : 480.0]), applied as a 
swab or gargle, 427 

Salt solution (7 : 1000) , as a spray in nasal 
diphtheria, 742 

Tincture of the chloride of iron, 748 

Tonics, such as quinine, strychnine and, 
the chloride of iron, as supportive meas- 
ures, 748 

DROPSY, 748 

Acet-theocin-sodium, 509 

Acupuncture, less favorable than incisions, 

only to be resorted to after other reme- 
dies fail, 535 
Adonidin, useful in cardiac dropsy, 74 
Apocynum, in cardiac or renal dropsy of 

the subacute or chronic type, 110, 752 
Caffeine, in cardiac or renal dropsy, 752, 

in torpidity of kidneys, 162 
Calomel and digitalis, in renal and cardiac 

types, 373, 752 
Colocynth, compound extract of. gr. 5 to 

15 (0.3-1.0), 239, 751 - 
Copaiba, of service in slow renal types, 242 
Digitalis, 1U 5 to 15 (0.3-1.0), with can- 

tharides, 1TL 1 (0.06) thrice daily, in 

renal torpidity due to heart trouble, 751 
Diuretin useful in all conditions, except in 

the presence of acute nephritis, 482 
Elaterium, especially useful in renal dropsy, 

261, 750 
Jalap, compound powder of, gr. 20 to 30 

(1.3-2.0), with potassium bitartrate, gr. 

15 (1.0), added, especially serviceable in 

renal dropsy, 339, 750 
Magnesium sulphate, in concentrated solu- 
tion, before breakfast, 357, 751 
Milk diet, very useful, 751 
Paracentesis abdominis, very useful in 

ascites, 752 
Pilocarpine, useful in localized and renal 

dropsy, contraindicated in cardiac types, 

442 
Pituitrin, TO. 15 (1.0) twice a day, is often 

efficient in cardiac dropsy, 752 
Potassium bitartrate with gin, in dropsy 

due to chronic nephritis, 451 
Potassium iodide, in hepatic cirrhosis and 

localized effusions, to remove liquid, 752 
Scoparius, infusion, may be used, 476 
Senega, rarely of value, 478 
Squill with digitalis, prescription for, 488, 

752 



990 



INDEX OF DISEASES AND REMEDIES. 



Strophanthus, in cardiac dropsy, 494 
Sugar of milk, useful as a diuretic, 495, 751 
Tapping in ascites, the best method, 752 

DYSENTERY, 739 

Antidysenteric serum in bacillary dysen- 
tery, 548 

Arsenic, 119 

Bichloride of mercury, gr. ^^ (C.0003), if 
passages are slimy and bloody, 371, 740; 
injections (1 : 50C0), followed by solu- 
tion (1 : 30,000) to prevent toxic effect 
by absorption, 741 

Boric acid, 3j to Oj (4.0 :"480.0), or phenol- 
sulphonate of zinc, gr. 15 to 1 quart (1.0 : 
960.0), very useful as rectal injection, 741 

Calomel, in purgative dose, contraindicated 
if weakness exists, 372, 272, 740 

Continuous irrigation with two-way tube, 
of great value, 741 

Copaiba, 242 

Copper sulphate, gr. 2 to the pint (0.12 : 
480.0), for irrigation of the colon, 243 

Creolin enemata, 245 

Emetine hydrochloride, gr. \ to § (0.03- 
0.04), in 30 minims of normal salt solu- 
tion, an efficient substitute for ipecac, 
329, 740 

Ergot, useful in bloody stools, 264 

Hammamelis, injections, if much blood is 
present, 740 

Ipecac, best remedy in acute dysentery, 
and is useful to prevent abscess if used 
early in amoebic dysentery and hepatitis, 
330 

Irrigation of colon, 582, 741 

Lead acetate, with opium and camphor, 
prescription for, 348 

Nitrohydrochloric acid, if due to defective 
action of secretory glands, 395 

Prescription for enema, 740 

Quinine injections, useful in amoebic dysen- 
tery, 220, 740 

Silver nitrate, rectal injections (gr. 10 to 
20 to the pint [0.6-1.3 : 480.0]), if ulcers 
are chronic; followed by salt solution if 
action is too severe, 388, 740 

Sulphate of magnesium, 357, 740 

Taraxacum, in dyspepsia due to hepatic 
torpor, 507 

DYSMENORRHEA, 753 

Amyl nitrite, often relieves, 98 

Antipyrine or acetanilide, in neuralgic at- 
tacks, in other cases of doubtful value, 
107, 754 

Belladonna, suppository, gr. \ (0.03)^ of 
extract of ointment applied to os; tinc- 
ture, internally, useful to relax spasm, 
142, 753 

Camphor with acetanilide, in pill, useful in 
nervous cases, 171 

Cannabis indica and gelsemium, often of 
service, 176, 754 

Corpus luteum useful in some cases, 244 

Epsom salt or aloes, if constipation is 
present, 753 

Ether or chloroform, 754 

Gelsemium, in spasmodic forms, 291 

Hot sitz-bath, followed by turpentine 
stupe, and Dover's powder, gr. 10 (0.6), 
often relieves, 586, 753 



Iron, strychnine, and quinine as tonics, 
with rest and horseback riding for 
anaemic and run-down patients, 754 

Opium, to relieve spasm and pain, 412, 753 

Piscidia erythrina, extract, in the dose of 
from \ to 2 fluidrachms (2.0-8.0), 445 

Potassium bromide, 154 

Water, cold and hot, alternately dashed 
over loins in atonic cases, 754 



DYSPEPSIA. (See Indigestion.) 

Ammonium chloride, in painful dyspepsia 
due to hyperacidity, 95 

Arsenic, useful in atonic types associated 
with chronic diarrhoea, 119 

Benzo-naphthol, in fermentative dyspepsia, 
146 

Bismuth subgallate, in fermentative dys- 
pepsia, 147 

Bismuth, when due to acid fermentation, 
146, 147 

Bryonia, when due to gastric and intestinal 
atony, 159 

Gentian, 292 

Hydrastis, as an antiseptic and curative 
agent in chronic types, 305 

Hvdroohloric acid, if gastric secretion is 
deficient, 307 

Lavage, in fermentative dyspepsia, 610 

Nitric acid with bitter tonics, often relieves 
intestinal types, 391 

Permanganate of potassium, 427 

Quassia, useful, if not due to gastritis, 457 

Serpentaria, as a tonic in atonic types, 480 

Strontium bromide, in painful dvspepsia, 
492 

Terebene, useful as an antiseptic in fer- 
mentative dyspepsia, 507 



DYSPNCEA, 754 

Ammonium carbonate, as a respiratory and 
cardiac stimulant, 755 

Arsenic, continuously employed, useful in 
emphysema and chronic pulmonary in- 
flammation, 756 

Dry cupping over back, when due to car- 
diac or pulmonary trouble, 755 

Heroin said to be of value in ursemic dysp- 
noea, 300 

Hyoscine, contraindicated, 755 

Morphine, gr. \ to \ (0.008-0.015) night 
and morning, often cures when due to 
nervous or cardiac disorders, 415, 755 

Opium, if due to nervous disorders, 754 

Strychnine, in idiopathic types and when 
due to bronchorrhoea in old people, 403, 
754 

Thoracentesis if there is pleural effusion, 
755 

EAR (DISEASES OF). 

Bismuth subgallate, useful in purulent 
otitis media, 147 

Glycerin, useful to soften impacted ceru- 
men, 294 

Potassium permanganate, solution, useful 
in purulent otitis media, 427 

Scarlet red to aid healing in perforation of 
tympanic membrane, 475 



INDEX OF DISEASES AND REMEDIES. 



991 



EARACHE, 755 

Cardiac sedatives, 755 

Chloroform, on swab, behind and in front 
of ear in otalgia, 757 

Cocaine, TU 1 to 3 (0.06-0.2) of a 4 per rent, 
solution of adrenalin chloride (1 : 5000 
solution, dropped into nostril, followed 
by spray if mucous membrane is en- 
gorged, 756 

Heat, dry, applied to head on affected side, 
755 

Inflation of Eustachian tube with Politzer's 
air-bag, 756 

Irrigation with normal salt solution hot as 
can be borne, gives great relief, 756 

Leeching behind ear, to relieve pain, 755 

Menthol and albolene spray, following 
cocaine, 756 

Poultices, oil and laudanum, contraindi- 
cated, 755 

Puncture of tympanum, if it bulge, fol- 
lowed by careful cleansing and insuffla- 
tion of boric acid, 756 

Tincture of belladonna and of opium 
dropped into the ear, 755 

ECLAMPSIA, 898 

Amyl nitrite, dangerous, 97 

Ansesthetics of little use, 900 

Croton oil, 2 minims (0.1), mixed with 
sweet oil, placed on tongue, 899 

Elaterium. gr. \ (0.015), rubbed up with 
butter, or compound jalap powder and 
calomel, may be substituted for croton 
oil, 899 

Extraction of child rapidly as possible, if 
attack comes on during labor, 900 

Hot-air bath, hot pack, or hot tub bath to 
induce sweating, 899 

Ice-bag to head wdnle in warm pack, 899 

Lumbar puncture, 900 

Morphine, veratrum, and amyl nitrite may 
be held in reserve, to be used if neces- 
sary, 900 

Parathyroid gland, 423, 900 

Pilocarpine contraindicated, 899 

Sodium bicarbonate, Bj-Oij, by Murphy 
drip, to combat acidosis, 899 

Thyroid gland, full doses, for early symp- 
toms of eclampsia, 514 

Transfusion, 627 

Venesection, hot wet pack, and croton oil, 
TTl 2 (0.12), with sweet oil on tongue to 
eliminate poison, 637, 899 

Veratrum in full doses, 529, 900 

ECZEMA, 757 

Ammoniated mercurv in chronic dry form, 

368 
Arsenic, only when skin is very dry, 118, 759 
Bismuth subgallate in weeping eczema, 146 
Black wash of value in, 372, 757 
Calamine in moist eczema, 531 
Cantharis, internally, in small doses, 178 
Dermatol, in weeping eczema, 147 
Green soap, 481, 759 
Hygienic measures and diet, 757, 759 
Ichthyol ointment, highly recommended, 

315 
Internal treatment, 759 
Iodoform ointment, prescription for, 326 



Iron, syrup of iodide, in young children 
with anaemia and debility, 336 

Kaolin as a dusting-powder, 341 

Lead, dilute solution of subacetate, a useful 
lotion, 349 

Liquor carbonis detergens, in acute cases, 
758 

McCall Anderson's ointment, 757 

Methyl blue in eczema of the eyelids, 380 

Ointments, prescriptions for, 327, 757, 758 

Phenol ointment (minims 10 [0.6] to cerate 
1 ounce [30.0]), to prevent itching, 432, 
758 

Poultices, or olive oil with phenol (TTl 1 to 2 
to the ounce [0.05-0.1 : 30.0]), followed 
by soap and water, necessary in some 
cases to soften scales, before use of 
ointment, 758 

Prescription of iodol, as an ointment, about 
nose and lip, 328 

Resorcinol ointment (gr. 2 to 30 to the 
ounce [0.12-2.0 : 30.0]), locally applied 
in subacute types; in chronic form, oint- 
ment (gr. 2 to 10 to the ounce [0.12-0.6 : 
30.0]), solution, gr. x to xv (0.6-1.0) to 
f§j (30.0), in itching of erythematous 
form, 459, 758, 759 

Salicylic acid ointment (gr. 30 to 60 [2.0- 
4.0) to lard 1 ounce [30.0]), in chronic or 
weeping types, 467, 759 

Starch poultice, in crusty eczema, 490 

Tar ointment, in chronic forms, 506 

Unna's dressing, 532 

Zinc carbonate, as a protective powder in 
weeping eczema, 531 

Zinc oxide, as a dusting-powder or oint- 
ment in early stages, applied directly 
or on lint, generally preceded by black 
wash, 532, 757 



EMISSIONS, 759 

Bromide of sodium, or potassium gr. 20 

(1.3) at bedtime, valuable in spinal 

irritabilitv, 153, 760 
Chloral, gr. 20 (1.3) at bedtime, 760 
Cold sponging of perineum and scrotum, 

559, 760 
Gold and sodium chloride in nocturnal 

emissions, 296 
Hygienic measures, 760 
Hyoscine gr. T -J^ (0.0006). of great value, 

313, 760 
Monobromated camphor, very usefid in 

spermatorrhoea, 174 
Potassium citrate, gr. 20 (1.3) thrice daily, 

to render urine non-irritating, 760 
Strychnine and arsenic, in full dose, of 

great service in genital atony, 760 
Warm bath before retiring, often useful, 760 



EMPHYSEMA OF LUNGS. 

Climatic treatment, 619 

Cod-liver oil, useful, 235 

Ethyl iodide, 280 

Euphorbia pilulifera, § to 1 drachm (2.0- 

4.0) of the fluidextract, 283 
Iodide of potassium, 318, 324 
Physostigma, aids in expellingmucus, 439 
Strychnine, 403 



992 



INDEX OF DISEASES AND REMEDIES. 



EMPYEMA. 

Bismuth subcarbonate with petrolatum, 
33 per cent., by injection, 148 

Iodine, gr. 6 (0.4) ; potassium iodide, gr. 6 
(0.4); water, 1 pint (500.0), as an irri- 
gating fluid, used daily, 324 

Pulmonary exercise to aid drainage, 600 

ENDOCARDITIS, 760 

Aconite, tincture of, TTL 3 (0.2) hourly, in 
early stages of acute sthenic types, 760 

Antistreptococcic serum in ulcerative endo- 
carditis, 551 

Blisters on prsecordium, to prevent endo- 
cardial complications, 761 

Ice-bag over prascordium, 558, 761 

Iron, tincture of chloride, associated with 
supportive treatment, in purulent types, 
761 

Veratrum, used for same purposes as 
aconite, 761 

ENTERIC FEVER. (See Typhoid 
Fever.) 

ENTERITIS. (See Dysentery and 

DlARRHCEA.) 

EPIDIDYMITIS, 792 

Guaiacol ointment, 5 per cent., to relieve 
pain, 793 

Guaiacol used locallv, highly recommended, 
298 

Heat, moisture, and pressure, in later 
stages, to relieve induration, 793 

Iodide of potassium, gr. 3 to 5 (0.2-0.3) 
thrice daily, to remove induration, 793 

Iodine, painted over scrotum, said to be 
beneficial, 577, 793 

Leeches on the perineum, 614 

Magnesium sulphate solution to relieve 
pain. 358, 793 

Mercury and belladonna ointments, equal 
parts, or iodine, gr. 4 (0.25), with lanolin, 
ounce 1 (30.0), locally applied, to relieve 
induration, 793 

Punctures, useful to relieve tension and 
alleviate pain, 793 

Rest in bed, elevation of pelvis and tes- 
ticles, cessation of local gonorrhceal 
treatment, and administering treatment 
for acute inflammation, 793 

Silver nitrate solution, painted over scro- 
tum, in early stage, may relieve, 389, 577 

Strapping and suspending testicle, to reduce 
inflammation, 577, 792 

EPILEPSY, 761 

Acetanilid, 67, 767 

Adonis vernalis with bromides have been 
found useful, 74, 765 

Amyl nitrite, inhalations, when aura is 
perceived and also in status epilepticus 
to relax spasm, 97, 766 

Anaesthetics contraindicated in all cases 
except status epilepticus, when chloro- 
form may be used to control attack, 766 

Antifebrin and antipyrine, especially useful 
in some cases, 107, 767 

Belladonna, with bromides, recommended, 
765 



Bleeding for the status epilepticus, 766 

Borax may be used, 149, 768 

Bromide of ammonium, should be used with 
other drugs, 93, 764 

Bromide of calcium, 157 

Bromide of gold, 157 

Bromide of iron, when ansemia is present, 
764 

Bromide of lithium, highly recommended 
in some cases, 157, 764 

Bromide of nickel, 157 

Bromide of potassium, the most reliable 
in ascending dose, 153, 762 

Bromide of sodium, not so apt to disorder 
stomach, 157, 764 

Chloral, alone or with bromides, well 
diluted after meals, used with care, 190, 
767 

Diet, 768 

Digitalis, with bromides, useful in some 
cases, 765 

Duboisine, especially in psychic forms, 261 

Hydrobromic acid, liable to derange diges- 
tion, 158, 764 

Iodide of potassium, useless except in 
syphilitics, 767 

Mercury, associated with potassium iodide, 
when due to gumma, 767 

Mixed treatment, 764 

Monobromated camphor, 173 

Nitroglvcerin, useful in some cases of 
petit mal, 393, 766 

Opium with gelsemium, only to be used 
whe,n other remedies fail; also a pro- 
longed course of, in ascending doses, 
useful in old cases, 765 

Potassium or sodium nitrite, used to 
supplement amyl nitrite, 392, 766 

Quassia injections, when due to worms; 
if not obtainable, sodium chloride solu- 
tion may be used, 768 

Silver nitrate may be tried when other 
remedies fail, 388, 766 

Solanum carolinense, fluidextract of, 2 to 
15 minims (0.12-1.0) thrice dailv in the 
epilepsy of childhood, 487, 768 

Strontium bromide, 492, 764 

Tartar emetic ointment, as a counter- 
irritant at back of neck, 102 



EPISCLERITIS, 768 

Antiseptic collyria, 769 

Atropine locally, 769 

Dionin, 5 per cent., to relieve pain, 769 

Eserine or pilocarpine if there is a rise of 

intra-ocular tension, 769 
Hot compresses, 769 
Iodide of potassium and salicylates, 769 
Tuberculin when tuberculous in origin, 769 
Yellow oxide of mercury ointment, gr. j- 

3j, for massage of eyeball, 769 



EPISTAXIS, 769 

Acetanilid used locally, has been recom- 
mended, 67 

Acetic acid, locally applied to arrest, 68 

Aconite or veratrum, tincture, 1U 6 to 12 
(C.4-0.8), in sthenic cases, followed in 
thirty minutes by smaller doses, if 
necessary. 73, 769 

Adrenalin, locally, 501, 769 



INDEX OF DISEASES AND REMEDIES. 



993 



BacoD fat, inserted as a plug in nostril, 

may arrest, 770 
Compound tincture of benzoin on cotton to 

place in nasal chamber to control, 769 
Compression of facial artery may be neces- 
sary, 770 
Cotarnine, locallj', 245 
Ergot, turpentine, hamamelis, or oil of 

erigeron, internally in slow oozing, 264, 

769 
Hot foot-bath, or hot- or cold-water bags 

applied to dorsal vertebrae, may arrest, 

770 
Ice applied to nose, may arrest, 770 
Ipecac, in nauseating doses, recommended, 

769 
Monsel's solution, in spray (HI 5 to 1 

ounce [0.3:30.0]), only to be tried 

when other remedies fail; very disagree- 
able, 338, 769 
Oil of erigeron, 265, 769 
Plugging anterior and posterior nares, if 

necessary, with cotton or lint soaked in 

vinegar, 769 
Vinegar or lemon-juice injected into nostril, 

770 

EPITHELIOMA. 
Acid nitrate of mercury, applied to part 

with glass rod, 376 
Arsenic trioxide and gum acacia (of each 

1 ounce [30.0] to water 5 fluidrachms 

[20.0]), locally applied, 119 
Carbon-dioxide snow, 556 
Resorcinol, in epithelioma of the face, 459 

ERYSIPELAS, 770 

Alcoholic stimulants, if patient passes into 
typhoid state, 771 

Aluminum acetate useful, 88 

Antistreptococcic serum, 551 

Bitters and iron, during convalescence, as 
tonics, 771 

Boric acid, as a lotion, 150 

Cold bathing to control excessive fever, 771 

Ichthyol ointment and vaseline, half-and- 
half, locally applied, preceded by wash- 
ing with Castile soap, followed by 
bichloride solution (1 : 1000), 315, 771 

Iodine, tincture, painted around inflamed 
edges, to arrest, 323 

Iron, tincture of chloride, TO. 10 (0.6) every 
hour, well diluted, best internal treat- 
ment, 335, 770 

Magnesium sulphate solution excellent, 358 

Phylocogens, 623 

Pilocarpine, gr. f to £ (0.008-0.01), hypo- 
dermically, contraindicated in debility; 
also injected around borders of inflam- 
mation in some cases, to arrest, 443, 770 

Silver nitrate, solution (gr. 80 to \ ounce 
[5.3 : 16.0]), applied twice or thrice to 
arrest, 389, 771 

White-lead paint, locally applied when 
ichthyol is not at hand, 771 

EXHAUSTION AND DEPRESSION, 771 

Stimulants, 772 

EXOPHTHALMIC GOITRE. 

Belladonna relieves some cases, 143 
Cannabis indica acts as a nervous sedative, 
176 

63 



Lecithin as a tonic, 350 
Pituitrin useful, 446 
Sparteine, 476 
Thyroidectin, 515 

EYE-STRAIN, 772 

Correct error of refraction, 772 
Gelsemium, in headache due to eye-strain, 
291 

FEET (SWOLLEN, TENDER, OR 
SWEATING), 772 

Arsenic trioxide, gr. / to f 6 (0.001-0.0015) 
in swelling of old persons, 119, 772 

Borax, stockings soaked iD saturated solu- 
tion and dried, each day, when sweating 
is excessive, 773 

Carbonate of calcium, precipitated, locally 
applied to sweating feet, 165 

Cotton instead of woolen stockings may 
aid cure, 773 

Formaldehyde, 773 

Hamamelis, distilled or fluidextract, 

drachm § to 1 (2.0-4.0) of former, or 1U 
10 to 20 (0.6-1.3) of latter, 773 

Lead plaster and linseed oil, equal parts, 
applied on linen to feet, every third day, 
for sweating, 350 

Prescription for dusting-powder, 773 

Rest, absolute, of feet, may be necessary in 
swollen feet, 773 

Salicylic acid and borax, equal parts, in 
water and glycerin, best application to 
sweating and tender feet, 773 

FELON. 

Bread-crumbs saturated with liquor plumbi 
subacetatis, as a poultice, to abort, 350 

Phenol locally to cause anaesthesia in 
opening, 432 

Silver nitrate solution, applied early, to 
abort, 389 

FEVER, 773 

Acetanilide, 66 

Aconite, the best depressant for sthenic 
types in children, 73 

Alcohol, as a systemic support and stimu- 
lant in low fevers, 78 

Ammonia for sudden cardiac failure in, 90 

Antimonial powders as an antipyretic, 102 

Antipyretics, useful in most sthenic fevers, 
often fail in thermic fever, 773, 774 

Antipyrine, 106 

Brand's method, 567 

Camphor a diffusible stimulant in ady- 
namic fevers, 172 

Capsicum as a stimulant in low fevers, 180 

Coca a supportive and stimulant in low 
fevers, 231 

Cold applications and baths, 563, 774, 775 

Cold packs and baths in asthenic types to 
be relied on first; if impracticable, then 
antipyretics, 775 

Digitalis, in small doses, valuable in ex- 
hausting fevers, 256 

Guaiacol, useful in, 297 

Hvdrochloric acid in adjuvant to digestion, 
307 

Musk, by rectal injections, valuable in low 
stages, 383 



994 



INDEX OF DISEASES AND REMEDIES. 



Neutral, mixture useful as a febrifuge, 

especially in children, 453 
Phenacetin, 69 

FIBROIDS. 

Ergot, used as an expulsive and curative 
remedy, 264 

FLATULENCE. 

Aromatic powder, 224 

Asafcetida, 133 

Beta-naphthol in gastric fermentation and 

flatulence, 145 
Camphor, 171 

Capsicum prevents formation of gas, 179 
Charcoal, 181 
Chloroform, HI 1 to 2 (0.06-0.12), or spirit 

Til 10 to 20 (0.6-1.3). will relieve, 207 
Cloves, a useful tonic and stimulant, 226 
Ginger, 292 
Hoffmann's anodyne, the best carminative, 

275, 302 
Pepper, 424 
Peppermint, 424 
Podophyllin with euonymin, leptandra, 

chirata, and creosote, 448 
Potassium permanganate, 427 
Turpentine, prescriptions for, 524 

FRECKLES AND CHLOASMA, 775 

Almonds, emulsion of, supposed to be of 
value, 84 

Boric acid, saturated solution, applied same 
as corrosive sublimate wash, 150, 776 

Corrosive sublimate (gr. 1 to 4 to the ounce 
[0.06-0.25 : 30.0]), applied night and 
morning until irritation appears, then 
stop for some days and again renew, 
776 

Lactic acid (gr. 10 to the drachm [0.6 : 
4.0]), applied same as corrosive subli- 
mate, ^6 

Prescription for, 776 

Prescription for chloasma of pregnancy, 532 

FURUNCLES. (See Botls.^) 

GALACTORRHCEA, 897 

Antipyrine, gr. 2\ (0.15) thrice daily, said 
to decrease secretion, 897 

Belladonna, 141 

Caustic, introduced into uterus, successful 
in some cases bv inducing menstrual 
flow, 897 

Chloral should be tried, 897 

Compression of gland with applications of 
belladonna ointment and potassium 
iodide internally, usually relieves, 897 

Diet, 897 

Electricity, generally ineffective, 897 

Ergot, long continued, highly recom- 
mended, 897 

Malt, wineglassful at midday and evening 
meals, useful addition to diet; pyro- 
phosphate of iron, gr. 4 (0.25), in addi- 
tion, if anaemia is present, 898 

Warm douches, 897 

GANGRENE. 

Bromine, as an escharotic in hospital gan- 
grene, 158 



Nitric acid, to destroy tissue, 391 
Phenol or creosote, spray (TTL 5 to 15 to 
the ounce [0.3-1.3 : 30.0]), useful in pul- 
monary gangrene, 431 

GASTRALGIA. 

Acetanilid, 67 

Bismuth and pepsin, after meals, to pre- 
vent pain, 147 

Bromide of strontium, a valuable remedy, 
492 y 

Cannabis indica, prescription for, 176 

Chloretone, gr. 5 to 10 (0.3-0.6), is useful, 
193 

Counterirritation and a vigorous revulsive, 
especially useful in hysteria, 577 

Hydrocyanic acid, useful in nervous types, 
308 

Menthol, 425 

Nitroglycerin, 393 

Potassium nitrite, gr. 4 to 5 (0.25-0.3), 392 

GASTRIC ATONY. 

Arsenic, prescription for, in, 115, 119 
Prescription for, in drunkards, 81 

GASTRIC CATARRH (ACUTE), 776 

Ammonium muriate, useful in subacute 
forms in children, prescription for, 95 

Bismuth hydroxide, 148 

Bismuth subnitrate, gr. 2 (10.2). and 
cerium oxalate, gr. 1 (0.06), every two 
hours, 777 

Calcined magnesia, as a mild purge to dis- 
lodge fermenting mass, 777 

Diet, principal point in treatment, 776 

Effervescing draughts, useful in convales- 
cence, 777 

Flannel, to protect abdomen. 777 

Ice, to quench thirst, if anorexia is great, 
777 

Iron, if anaemia exists, 777 

Milk, with large percentage of lime-water, 
776 

Salicylic acid, valuable in vomiting, 467 

Seidlitz powder, one-fourth of one powder 
every fifteen minutes, to settle stomach 
and remove fermenting mucus, 777 

Sodium bicarbonate with gentian, useful, 
483, 777 > 

Spice poultice to relieve epigastric distress, 
578, 777 

GASTRIC CATARRH (CHRONIC), 777 

Apomorphine, as an emetic, to throw off 

mucus, 111 
Arsenic for the vomiting, in hand-fed 

babies, 118 
Bicarbonate of sodium for hyperacidity, 777 
Bismuth subnitrate, added to prescription, 

if hyperacidity exists, 777 
Carlsbad salt, Saratoga-Carlsbad water, or 

Seidlitz powder of great benefit, 777 
Cascara sagrada, if constipation exists, 778 
Charcoal, prescription for, 181 
Diet, such as koumyss, light broths, and 

matzoon, 778 
Hydrochloric acid, if due to atrophy of the 

gastric tubules, 307, 778 
Hyoscyamus useful with silver nitrate, 311 



INDEX OF DISEASES AND REMEDIES. 



995 



Lavage, almost always to be used, 777 
Silver nitrate and hyoscyamus, with coun- 
terirritation and regulated diet, 388, 777 



GASTRIC DILATATION, 778 

Beta-naphthol, if fermentation is marked, 
779 

Cold douches, 779 

Diet, 778 

Enemas, nutrient, often useful, especially 
in older children, 778 

Exercise, 779 

Faradization of gastric walls, recently intro- 
duced, 779 

Hydrochloric acid, to aid digestion, 307, 779 

Lavage, 610, 778, 779 

Physostigma useful, combined with nux 
vomica, 438 

Salicylic acid as an antiseptic when vomit- 
ing occurs and when the vomited matter 
contains sarcinse, 467 

Taka-diastase taken with meals, 778 



GASTRIC AND DUODENAL ULCER, 

779 

Adrenalin chloride solution, 3J (4.0), some- 
times gives good results in relieving 
vomiting, 782 

Arsenic, 118 

Bismuth and sodium bicarbonate, as an 
astringent and sedative, and to these 
may be added morphine, dionin or 
codeine for pain, 147, 781 

Carlsbad salt, magnesium sulphate, or 
sodium phosphate for relief of constipa- 
tion, 781 

Chloretone of value to relieve pain, 193, 781 

Cocaine, gr. \ (0.015), alone or combined 
with bismuth, to control vomiting, 781 

Cold compresses or an ice-bag applied to 
epigastrium in hgematemesis, 782 

Counterirritation, continuous, over belly 
to relieve pain, 781 

Creosote or carbolic acid for vomiting, 781 

Diet and hygiene, 779, 780 

Dionin as a substitute for morphine, 260 

Hypodermoclysis, 780 

Lenhartz's treatment, 780 

Massage and electricity, 780 

Milk of magnesia, § ounce, at bed-time to 
relieve distress of duodenal ulcer, 782 

Mineral oil to soothe duodenal ulcer and 
prevent intestinal stasis, 782 

Monsel's solution, cold compresses, or adre- 
nalin chloride, may be given to check 
haamatemesis, 782 

Morphine for pain or collapse following 
perforation, 782 

Orthoform may relieve pain, 418 

Rectal alimentation, of great service, 781 

Resorcinol, useful in some cases, 459 

Rest for the patient and rest for the stom- 
ach essential, 778, 780 

Silver nitrate with hyoscyamus in pill, half 
to one hour before meals, 312, 388, 781 

Sodium bicarbonate, \ drachm, between 
meals, in duodenal ulcer to overcome gas- 
tric hyperacidity with pyloric spasm, 782 

Sodium citrate, 484 

Spice plaster, useful as a continuous coun- 
terirritant, 781 



Stimulants, cardiac, guardedly adminis- 
tered, external heat and rubbing, in col- 
lapse, following hemorrhage or perfora- 
tion, 782 

GASTRITIS (ACUTE), 783 

Belladonna or atropine, internally, and 
flaxseed poultice over epigastrium and 
chest, if collapse threatens, 783 
Bismuth, as an astringent and sedative, 146 
Flaxseed tea, a useful demulcent, 285 
Mucilaginous drinks and albuminous sub- 
stances freely given, 783 
Oils, to prevent spread of inflammation, 783 
Opium, in fluid form, to relieve pain and 

irritation, 783 
Paregoric contraindicated, 783 
Sodium citrate, 484 

Warm water, internally, or stomach-pump, 
to unload stomach at onset, 783 

GASTROENTERITIS, 783 

Castor oil or magnesium sulphate, to sweep 
out poison, 784 

Morphine hypodermically, to allay pain, 
followed or preceded by mild, rapidly 
acting emetic, if irritating substance 
remains, 783 

Opium, with hot applications or plasters 
to belly, to control irritation and diar- 
rhoea, 784 

Predigested food, 784 

GASTROINTESTINAL CATARRH. 

Ammonium chloride useful in subacute 

types in children, 94 
Carlsbad, Vichy, or other alkaline mineral 

water of purgative powers, often useful, 

617 
Diet for seven-year-old child, 647 
Garlic, as a poultice to belly almost equal 

to spice poultice. 83 
Gentian with bicarbonate of sodium useful 

in children, 292 
Hvdrastis, especially useful if due to alco- 
holism, 305 
Ichthyol internally, 315 
Sanguinaria, of service if jaundice is 

present, 472 
Sodium bicarbonate, 10 to 20 grains, 483 
Subsalicylate of bismuth in the presence of 

fermentation or putrefaction, 148 
Tar, in 2-gr. (0.12) pills, 506 

GIDDINESS. 

Cod-liver oil with quinine, valuable in old 

age, 235 
Ergot and bromides useful, 264 

GLANDS (DISEASED). 

Ammonium iodide and glycerin (gr. 30 to 
the ounce [2.0 : 30.0]), locally applied to 
enlarged tonsils, 95 

Cod-liver oil, in lymphatic enlargements, 
234 

Counterirritation, 575 

Ichthyol ointment, valuable as an inunc- 
tion in lymphatic enlargements, 315 



996 



INDEX OF DISEASES AND REMEDIES. 



Iodine, the best remedy for enlargements, 
321 

Mercury ointment as an inunction in en- 
larged glands, 375 

Phenol (2 per cent, solution), injected into 
glands threatening suppuration, 432 

Potassium iodide for enlargements of the 
cervical glands, 318 

GLAUCOMA, 784 

Atropine, contraindicated, 784 

Dionin in 1 to 5 per cent, solution, 260, 784 

Eserine (gr. 1 to 2 to the ounce [0.06-0.12 : 
30.0]), or pilocarpine nitrate (gr. 2 to 4 
to the ounce [0.12-0.25 : 30.C]), dropped 
into eye if operation is delayed, 439, 784 

Hot compresses, leeches, and opiates to 
relieve pain, 784 

Iridectomy, the only curative treatment, 
784 

Pilocarpine in, 442, 784 

Sodium salicylate, full doses, internally, 784 

GLEET. 

Bichloride of mercurv, injection (gr. \ to 
water 6 ounces [0.03 : 180.0]), every 
three or four hours, 371 

Cantharis, 178 

Sandalwood oil, 471 

Turpentine, internally, 525 

Uva ursi, 526 

GOITRE. (See Bronchocele.) 

GONORRHOEA (ACUTE), 785 

Aconite, TH. 6 (0.4) every two or three 
hours, if inflammation is high, 73, 789 

Almond emulsion, diminishes burning on 
urination, 84 

Argyrol, 1 to 10 per cent., as injection, 112, 
788 _ 

Benzoic acid, with cannabis indica, useful 
in later stages, 145 

Bicarbonate of sodium or potassium citrate, 
gr. 10 (0.6) after meals, increasing, if 
necessary, relieves ardor urinae, 788 

Cannabis indica, often used in later stages 
instead of copaiba and cubebs, 176 

Cinnamon oil, by injection or spray, 224 

Cocaine, solution (4 per cent.), instilled 
into urethra before urination, diminishes 
ardor urina?, 789 

Copaiba and cubebs, useful in later stages, 
242, -249, 786 

Erigeron oil, occasionally used instead of 
copaiba and cubebs, 265 

Eucalyptus, valuable in subacute stages, 
282 

Hot bath, prolonged, before going to bed, 
788 

Hydrastis, one of the best remedies, locally 
and internally, in later stages; also as 
a vaginal wash for females, 305 

Lead acetate, injection, gr. 1 to 8 to the 
ounce (0.06-0.5 : 30.0), 348 

Lead-water and laudanum, or alcohol and 
water, applied on a cloth to penis, dur- 
ing inflammation, 788 

Mercurol, 360 

Mercury bichloride in females, 2 pints of 
solution (1 : 4000) thrice daily, to irri- 
gate vagina, 794 



Methylene-blue, 381 

Nargol, argyrol, or protargol injections, 
1 to 10 per cent., 789 

Opium or belladonna, hypodermically or in 
suppository, to control pain in posterior 
urethritis, at same time discontinuing 
active treatment, and observing strict 
hygiene and diet, 789 

Permanganate of potassium solution (1 : 
6C00), as an antiseptic, 787 

Prescription for administration of balsams, 
786 

Prescriptions for checking the discharge, 
788 

Protargol, 456, 785, 786, 789 

Quercus, injections, useful in females, 458 

Salol (phenyl salicylate), 470, 786 

Silver nitrate, injections (gr. \ to 3 ounces 
[0.03-90.0]), useful in subacute stage; in 
females, gr. 4 to 40 to the ounce (0.25- 
2.6 : 30.0), painted over vagina, followed 
by astringent cotton tampon, 389, 790, 
794 

Silvol, 10 to 20 per cent, solution, by injec- 
tion, three or four times a day, may 
be used, 481 

Urinating with penis in hot water, to re- 
lieve ardor urinse, 789 

Vaccines in, 630 

Warm baths, lasting one-half to two hours, 
useful in early stage, 788, 789 

Zinc acetate, injection, gr. 1 to 20 to the 
ounce (0.06-1.3 : 3C.0) of rose-water, 531 

Zinc chloride, injection, gr. 1 to 2 to the 
ounce (0.06-0.12:30.0), occasionally 
used in second stage, 532 

Zinc sozoiodol, 2 per cent, solution, 487 

Zinc sulphate, weak solution, as an astrin- 
gent, 533 

GONORRHOEA (CHRONIC), 790 

Bichloride of mercury useful in, 372 

Copaiba useful, 242 

Copper sulphate or silver nitrate, solution, 
as an application, after dilatation, to 
focus of inflammation, 790 

Dilatation, if stricture exists, 790 

Irrigations daily with silvol, argyrol, or 
protargol (1 : 3000-1 : 500), silver nitrate 
(1 : 5000), mercurol (1 : 20C0), or potas- 
sium permanganate (1 : 2000-1 : 500), 790 

Prescriptions for, 790, 791 

Pressure and use of cold, often valuable, 791 

Sandalwood oil, to stimulate depraved 
mucous membrane, 471 

Silver nitrate, solution, if discharge per- 
sists after dilatation; also in posterior 
urethritis, 790 

Unna's treatment with coated sounds, pre- 
scription for, 790 

Uva ursi, 526 

GOUT, 794 

Antipyrine said to have a specific effect, 106 

Barbital or barbital sodium for insomnia, 
796 

Chloral, in insomnia, 796 

Chloroform liniment, applied over affected 
part, 208 

Cod-liver oil, 235, 796 

Colchicum, wine of seed, 1U 40 (2.6), in- 
creasing by 1U 2 (0.12) every four hours 
until symptoms are relieved or appear 
toxic, in acute types, 237, 795 



INDEX OF DISEASES AND REMEDIES. 



997 



Collodion, not more than one or two coats: 

also useful with iodine. 238, 795 
Diet, 795 
Fowler's solution, Tfl. 3 (0.2), in water, a 

standard remedy in subacute and chronic 

types, 796 
Gentian, 292 

Guaiac recommended as preventive, 29G 
Hot air, of little value, 596 
Hot baths useful, 617 
Iodide of iron, syrup of, and cod-liver oil 

if ansemia is present, 796 
Iodide of potassium, to relieve night pains; 

also with colchicum, in chronic gout, 795 
Iodine, ointment or tincture, locally applied 

to chronic gouty joints, 796 
Leeches or venesection, contraindicated, 

795 
Lithium carbonate or citrate (»r. 5 to 10 

to the ounce [0.3-0.6 : 30.0]), locally 

applied, to dissolve deposit around 

joints, 353, 796 
Morphine, hypodermically, to relieve acute 

pain. 795 
Novatophan relieves pain, 400 
Potassium permanganate. 427 
Saccharin, used instead of sugar, 463 
Salicylates in large dose, mav be useful in, 

466 
Sodium bicarbonate and linseed oil (1 : 9), 

locally applied to joints, 795 
Stimulants, ether hypodermically, opium 

except in brain or kidney disturbances; 

diuretic and alkaline drinks and counter- 
irritation, in retrocedent gout. 796 
Strontium bromide, the best remedy for 

insomnia, 796 
Water, distilled or medicinal, in large 

amounts, 794, 796 

GRANULAR LIDS. 

(See Conjunctivitis, Granular.) 

GRAVES' DISEASE. 

(See Exophthalmic Goitre.) 

GRIPING. 

Allspice or ginger, to prevent griping of 

purgatives, 444 
Belladonna useful,- 141 
Oil of peppermint, 424 

GROWTHS (PATHOLOGICAL). 

Acid nitrate of mercury, 376 

Caustic potash or soda, occasionally used 

to destroy, 454 
Chromium trioxide, as a caustic, to destroy 

growths on skin or mucous membranes 

212 
Hydrogen peroxide solution useful for 

cleansing malignant growths, 310 
Lime as an escharotic on hairv growths, 168 
Methvlene-blue, 381 
Nitric acid, 391 
Pyoktanin, 380 
Sodium ethylate to remove hairy growths, 

484 
Thiosinamine has been used with some 

success in malignant growths, 510 

GUMS (DISEASES OF;. 

Burnt alum, useful if applied to swollen 
gums, 88 



Gambir, as a mouth-wash, for spongy 
gums, 289 

.iodine, solution (gr. 1 to the ounce [006 : 
30.01), locally applied, followed by rins- 
ing mouth, when gums are retracted. 323 

Myrrh, tincture, locally applied, to spongy 
or tender gums, 384 

Thymol, prescription for, in tenderness 
after mercurialization, 511 

HEMATEMESIS, 815 

Adrenalin, 1 drachm of a 1 : 1000 solution, 

815 
Bandages to extremities and external heat if 

faintness ensues, 815 
Hamamelis, internally, 299 
Morphine to produce general and gastric 

rest, and to aid formation of a clot. 815 
Monsel's salt, gr. 2 to 3 (0.12-0.2), in pill. 

338 

HEMATURIA, 816 

Adrenalin chloride (1 : 500C) as injection, 

817 
Alum. gr. 2 to 3 (0.12-0.2). to water 1 

ounce (30.0). injected into bladder, if 

alarming, 817 
Astringent injections, should be used only 

when bleeding is alarming, 817 
Cups over kidnevs, 817 
Gallic acid. gr. 20 (1.3), very valuable. 288 
Hamamelis, injected daily into bladder or 

used internally. 299 
Morphine and atropine hypodermically and 

cups over kidneys in hsematuria, 817 
Quinine, usually harmful, unless due to 

malaria, 817 
Rhus aromatica, 461 
Sodium thiosulphate, 10 to 30 grains (0.6- 

2.0) every four hours, in malarial hsema- 
turia, 486, 817 
Turpentine, 525, 817 

HAEMOPHILIA. 

Calcium chloride, 166 

Calcium lactate, 166 

Coagulose, 556, 816 

Magnesium carbonate may be used, 356 

HEMOPTYSIS, 814 

Acetanilid has been recommended, 67 
Aconite, to prevent pneumonia following, 

contraindicated in exhaustion, 815 
Alum, solution (gr. 20 to the ounce [1.3 : 

30]), in fine spray. S7 
Amyl nitrite, used successfully by bleeding 

a man into his own bloodvessels, 97. 814 
Chloral and bromides, to allay nervous 

excitement, 815 
Chloroform, by inhalation with care, if 

nitrites are not available, 814 
Esmarch bandages to limbs when aconite 

cannot be used, because of exsanguina- 

tion, 814 
Gallic acid, gr. 20 to the ounce (1.3 : 30.0) 

of water, when ergot is not at hand, 288 
i Hamamelis, 299 
I Ice or ice-cold compress to the scrotum or 

vulva in, 815 
| Ice or dry cup over bleeding spot, 815 
, Ipecac, in small doses, very effective, 330 



998 



INDEX OF DISEASES AND REMEDIES. 



Morphine, hypodcrruically, to allay net 

vousness and cough, 413, 815 
Nitroglycerin, gr. T J to J (0. 0000-0.0015), 

393, 814 
Tannic acid, Monsel's solution, or alum 

used in spray, as styptics, prescriptions 

for, 338, 505, 815 

HAY FEVER. 

Adrenalin, locally, to relieve engorgement 

501 
Arsenic, 118 
Cocaine with bismuth and morphine, as a 

snuff, 228 
Pituitrin. diluted from three to ten times 

with normal salt solution, locally in place 

of adrenalin, 448 
Pollen proteins, 624 
Resorcinol, solution 2 per cent., in sprav, 

459 
Terpine hydrate, in full dose, 508 

HEADACHE, 796 

Acetanilid, 67 

Aspirin, in 10-gr. (0.6) doses, is verv useful. 
798 

Belladonna, valuable in young people, 143 

Bleeding. 797 

Caffeine, with antipyrine or sodium bro- 
mide, in nervous headache. 163, 798 

Calcium chloride or lactate, in persistent 
dull headache with decreased coagula- 
tion of blood, 166 

Camphor, with acetanilid or antipyrine, in 
nervous headache, 171 

Cannabis indica, when at menopause or 
due to retinal asthenopia, 176 

Capsicum plaster to nape of neck, 180 

Castor oil, daily, in neuralgic headache, 184 

Cimicifuga, if due to eye-strain, 214 

Colchicum, in gouty headache, 798 

Counterirritation, 577 

Croton chloral, if due to eye-strain or asso- 
ciated with sick stomach, 248 

Cup, to nape of neck, in congestion, 797 

Ergot, if due to congestion, 264, 797 

Eucalyptus, if headache be rheumatic or 
malarial, 282 

Gelsemium, if due to nervous troubles or 
eye-strain, 291 

Horseback exercise and sleep very useful 
in obtaining relief from nervous head- 
ache. 798 

Hydrobromic acid, if due to eye-strain in 
nervous women, 158 

Ice-bag, applied to head, or leeches behind 
ears, in severe cases, 797 

Kola, very useful in elixir or tincture for 
sick and neuralgic headaches, 342 

Liquor magnesii citratis, in sick headache, 
356 

Magnesium carbonate, gr. 5 to 60 (0.3-4.0), 
in sick headache due to gastric acidity. 
355 

Mercury, when due to syphilis, 365 

Mustard foot-bath and plaster to nape of 
neck, in congestion, 383, 797 

Nux vomica, TU 1 (0.06), every five or ten 
minutes till 10 minims (0.6) are taken, 
in sick headache, 404 

Phenacetin, if due to eye-strain or neural- 
gia, 70 



Potassium bromide 153 

Prescriptions for. 797, 798. 799 

Salicylic acid or iodide or acetate of potas- 
sium, if due to gout, 798 

Sodium bicarbonate, as an antacid in sick 
headache, 483 

Strychnine or nux vomica, in sick head- 
aches or if due to eye-strain, 404, 798 

HEART DISEASE, 799 

Aconite or veratrum, often useful in palpi- 
tation and hypertrophy, 73, 808, 810 

Aclonidin, often of service when digitalis 
fails, 74, 805 

Adrenalin intravenously in cardiac and 
vasomotor failure. 501 

Alcohol in heart failure due to shock or to 
poisons, 78 

Ammonia and ether, followed by digitalis 
and alcohol, in heart failure, 90. 807 

Amy! nitrite, in single whiffs, often relieves 
cardiac failure, 98 

Baths, Nauheim, formula for, 810. 811, 812 

Belladonna, when arrhythmia is present, 
807; in palpitation, 141 

Cactus grandiflora. useful in valvular dis- 
ease with incompetency, cardiac weak- 
ness, and palpitation, 160 

Caffeine, very useful, 162, 8C8 

Camphor, in palpitation, 172 

Cimicifuga, as a tonic in fatty and irritable 
heart when digitalis fails, 214 

Citrate or bitartrate of potassium with 
digitalis when secretion of urine is 
scanty. 808 

Climatic treatment, 621 

Convallaria majalis, in cardiac arrhvthmia, 
242 

Counterirritation, 575 

Diet, exercise, and hygiene, 807, 808 

Digestive remedies, in palpitation due to 
indigestion. 807 

Digitalis, to be tried in all heart troubles, 
except in simple or compensatory hyper- 
trophy , 256, 800, 801, 802, 803, 804, 808 

Electric cabinet bath or hot-air treatment, 
807 

Hoffmann's anodyne, very useful in palpi- 
tation due to indigestion or tobacco, 302 

Hydragogue cathartics for the dropsy and 
portal engorgement, 807 

Iodides to relieve tension in fatty heart, 807 

Iron, arsenic, and simple bitters, for asso- 
ciated debility and anosmia, 807 

Iron, in palpitation due to ana?mia, 807 

Kola, useful in cases with debility, 342 

Nitroglycerin, when arterial tension is high, 
394, 807, 810 

Nux vomica, as a stimulant, 807, 810 

Opium, if dyspnoea prevents sleep, 415 

Pituitrin useful in tachycardia and myo- 
cardial feebleness. 448. 807 

Potassium bitartrate or citrate with digi- 
talis for scantv secretion of urine. 808 

Rest cure valuable, 626, 800 

Rest in bed essential when aconite is used, 
810 

Sparteine, in arrhythmia for palpitation, 
also as a substitute for digitalis, if it 
fails, 476, 805 

Strophanthin or strophanthone, intraven- 
ouslv in presence of circulatory failure, 
803. 807 



INDEX OF DISEASES AND REMEDIES. 



999 



Strophanthus, if digitalis fails, 493, S03, 
804, 805, 807 

Suprarenal gland, in heart failure due to 
lack of vascular tone, 501 

Venesection followed by digitalis for over- 
distended right ventricle, 807 

Veratrum, 529 

HEMORRHAGE, S12 

Adrenalin in hemorrhage from small 
vessels, 501 

Alum, a useful styptic, applied to bleeding 
vessel, 87 

Antipyrine, 107 

Arnica, 113 

Blood-serum, 1 ounce (30.0) daily by hypo- 
dermic injection, should be resorted to, 
813 

Cinnamon, in uterine hemorrhage, 224 

Coagulose in hemorrhage of the newborn, 
556 

Compress, soaked in antiseptic liquid or 
filled with antiseptic powder, preferable 
to styptics, 813 

Ergot in postpartum hemorrhage, 263 

Gelatin, locally and hypodermically, to aid 
in the coagulation of blood, 813 

Hamamelis, useful for uterine oozing and 
bleeding from the bladder, 299 

Hypodermoclysis, 596, 813 

Intravenous saline injections, 609 

Ligation, preferable to styptics, when appli- 
cable, 813 

Monsel's solution, 338 

Oil of erigeron, 265 

Packing of astringents, if bleeding-point 
cannot be reached by compression or 
for ligation, 813 

Sulphate of sodium, by the mouth or intra- 
venously; useless hypodermically, 486 

Tannic acid, 504 

Transfusion, 627, 813 

HEMORRHAGE (INTESTINAL), 815. 
(See also Hemorrhage.) 

Adrenalin chloride, 816 

Coagulose and horse serum or human serum 
816 

Chloride of calcium,' 166 

Enemas, styptic, for hemorrhage from 
rectum or colon; adrenalin chloride, 2 
drachms of 1 : 1000 solution in \ pint of 
normal salt solution; alum (gr. 10 to the 
ounce [0.6 :30.0]), copper (gr. 5 to the 
ounce [0.3 : 30.0]), Monsel's solution (dr. 
\ to 2 ounces [2.0 : 60.0]), Monsel's salt 
(gr. 10 to the ounce [0.6 : 30.0], or 
drachm § [2.0] to water 2 ounces [60.0]), 
chlorate of potassium (gr. 10 to 25 to 
the ounce [0.6-1.6:30.0]), tannic acid 
(gr. 20 to the ounce [1.3 : 30.0]) of glycerin 
and water, 816 

Ergot, 263 

Ice-bag to the belly if patient is not in col- 
lapse, 816 

Ice-water injections in blood y purging of 
dysentery, S16 

Monsel's solution not advisable, 337 

Morphine hypodermically, 816 

Transfusion, 816 

Turpentine, in capsule or emulsion, when 
bleeding is not active, 525 



HEMORRHOIDS, 817 

Aloes, 86 

Antipyrine with cocaine in suppository, to 
check bleeding and relieve pain, 108 

Cocaine and iodoform ointment, prescrip- 
tion for, 818 

Cold-water injections in the morning re- 
lieve congestion and cause easy evacua- 
tion, 818, 819 

Ergot, sometimes useful in bleeding piles, 
264 

Gallic acid and ointment of stramonium, 
equal parts, 288 

Gallic acid and opium suppository, pre- 
scription for, 818 

Hamamelis, internally or as a lotion of 
injection, 299, 818 _ 

Hot compress wet with adrenalin chloride, 
1 : 2000, 818 

Hygiene and general rules, 818, 819 

Iodoform suppository, if ulceration is 
present, 327 

Lead-water and laudanum lotion, after 
acute stage is passed, 819 

Linseed oil, 286 

Nitric acid, lightly touched to one or two 
points; as a lotion, § to 1 drachm to the 
pint of water, in bleeding hemorrhoids, 
391, 818 

Phenol injection dangerous, 819 

Potassium chlorate, with laudanum, as an 
injection, 453 

Quercus, as an astringent wash, 458 

Stillingia, prescription for, 490 

Sulphur, to produce soft passages, 497 

HEPATIC ABSCESS, 820 

Active treatment for dysentery, if present, 

820 
Ammonium muriate, thought to be of 

value, 95 
Aspiration, when pus forms, 820 
Diet, 820 

Ipecac to prevent, 330 
Quinine and iron, after abscess develops, 

821 

HEPATIC CIRRHOSIS. 

Ammonium chloride, 95 

Iodoform, highly recommended, 327 

Liver, 3 oz. of fresh gland, in delirium of 

cirrhosis, and in alcoholic cirrhosis with 

icterus, 293 
Nitro-muriatic acid, in early stages, 395 
Potassium iodide, often useful in early 

stages, 318 
Sodium phosphate very useful, 485 

HEPATIC TORPOR. 

Ammonium chloride in, 95 

Citric acid in, 225 

Euonymus in, 283 

Nitro-hydro chloric acid when either acute 

or chronic, 395 
Potassium acetate very efficacious, 450 
Taraxacum, 507 

HEPATITIS (ACUTE), 820 
Cantharidal blister, small, over right hypo- 
chondriuni ; if impracticable, use mustard 
plaster, 820 



1000 



INDEX OF DISEASES AND REMEDIES. 



Hot cloths, over counterirritant, may re- 
lieve pain and aid in formation of blister, 
820 

Ipecac useful to prevent abscess, 330 

Saline purgatives, preceded by calomel, 
gr. 1 (0.06) , in divided doses, if constipa- 
tion exists, 820 

Sweet spirit of nitre with potassium citrate, 
or diuretic waters to regulate kidneys, 
820 

HEPATITIS (CHRONIC AND SUB- 
ACUTE), 821 

Ammonium chloride, useful in subacute 
forms, 95 

Antisyphilitic treatment, if due to syphilis, 
821 

Aspiration, frequently repeated, may effect 
a cure, 821 

Nitro-muriatic acid, internally and exter- 
nally, most useful remedy, 395, 821 

Potassium iodide, useful in all cases, 821 

HERNIA. 

Chloroform or ether inhalations, to relax 
muscles during reduction, 202, 275 



HERPES. 



Anthrarobin in, 



HICCOUGH, 821 

Amyl nitrite, 822 

Belladonna, 143 

Camphor, spirit of, dose, 1 drachm (4.0), 
172, 821 

Capsicum tincture, TU 2 to 3 (0.12-0.2), 
821 

Chloral, 190 

Chloroform, 821 

Emetics or purges when gastric or intestinal 
irritation is present, 821 

Ether, sprayed on epigastrium, 275, 822 

Hoffmann's anodvne, especially valuable, 
302, 821 

Hot pack when due to uraemia, 822 

Musk, gr. 10 (0.6), given by rectum, valu- 
able in all cases, especially in typhoid 
fever, 383, 822 

Nux vomica, accompanied by mineral 
acids, if due to indigestion, 822 

Oil of amber, TU 5 to 10 (0.3-0.6), in cap- 
sule, one of the best remedies, 89. 822 

Sodium bromide and laudanum by the 
bowel when life is threatened, 822 

Valerian, tincture of, dose, 1 drachm (4.0), 
821 

HYDROCELE. 

Iodine, injections, after evacuation of the 
sac, the best curative remedy, 323 

HYDROCEPHALUS. 

Potassium iodide to cause absorption of 
fluids, 318 

HYSTERIA. 

Calciuni bromide, 157 

Corpus luteum, dried, has been used, 293 

Hops, as a nervous sedative, 304 



Hyoscine as a hypnotic, 312 
Monobromated camphor, to produce sleep, 

173 
Oil of amber, 89 
"Pill of three valerianates," recommended, 

527 
Potassium bromide, 153 
Rest cure, 626 
Valerate of ammonium, 96 
Valerate of iron, if associated with anaemia, 

338 
Valerian, 527 

IMPOTENCE. 

Cannabis indica, with strychnine, nux 

vomica, or ergot, if no organic trouble 

exists, prescription for, 176 
C antharis, with nux vomica and iron, may 

restore sexual power if loss is due to 

excess, 178 
Gold, chloride of, and sodium, gr. ^ 

(0.003), 296 

INCONTINENCE OF URINE, 822 

Alkalies, 823, 824 

Ammonium benzoate or urotropin, gr. 4 
(0.25), in water, three times a day, if 
urine is concentrated and ammoniacal 
in odor, 823 

Antiseptic fluids, to cleanse bladder, in 
paralysis, 824 

Arsenic with nux vomica, in weakness of 
spinal centres, prescription for, 823 

Belladonna, if due to vesical spasm, 142, 823 

Bromides with chloral, if due to vesical 
spasm, 153 

Buchu, with sweet spirit of nitre, valuable 
in some cases, 160 

Cantharides, 1U \ (0.03), with alkaline 
diuretics, thrice daily, in adults, 178. 824 

Catheterization, in retention or paralysis, 
824 

Circumcision, if prepuce is redundant, re- 
lieves some cases, 822 

Fowler's solution, m \ to 1 (0.03-0.06), in 
chronic types due to atony, 823 

Hyoscyamus, if due to irritable bladder, 312 

Potassium citrate, when due to acidity, 453 

Rhus aromatica, in incontinence of chil- 
dren, due to atony, 461 

Santonin, often valuable when other rem- 
edies fail, 473 

Strychnine, 823 

Sweet spirit of nitre and potassium citrate, 
if urine is dark and concentrated, pre- 
scription for, 503, 823 

Worms removed from vagina often cure, 
822 

INDIGESTION (GASTRIC AND 
ESTTESTINAL), 824 

Alkalies, before meals in atonic states, dur- 
ing or after meals when the secretion of 
acid is excessive, 827, 828 

Ammonium acetate solution as an antacid 
in gastric indigestion, 92 

Ammonium chloride, in painful forms, 95 

Asafcetida, in indigestion of old age, asso- 
ciated with flatulence, 133, 829 

Bicarbonate of sodium with bitters, 825, 
826, 827, 828 



INDEX OF DISEASES AND REMEDIES. 



1001 



Bitter tonics, useful in atony, contra- 
indicated in gastric irritation, 825 

Bromide of strontium, in excessive secre- 
tion, when not due to ulcer, 492, 827 

Byronia, when dependent upon gastric or 
intestinal atony, 159 

Carbolic acid and bismuth, 827 

Chloral, creosote, sodium thiosulphate, or 
thymol, with lavage, when fermentation 
is excessive, 828 

Chloroform spirit, 1U xx (1.3), often of 
great value, 829 

Creosote, V([ \ to 2 (0 03-0.12), after meals 
in fermentation, due to deficient diges- 
tion of meats or the use of sweets, 247 

Diastase, when starchy foods are not 
digested, 250 

Diet, 825 

Fats, excluded in fermentative types, 828 

Gold, chloride of, and sodium, when epi- 
gastric pain is present, 295 

Hydrochloric acid, combined with carda- 
mom, in atrophy of the gastric tubules, 
cancer, or intestinal dyspepsia, 307, 826 

Hyoscyamus. belladonna, opium, bromides, 
bismuth, when there is hyperacidity, 
827 

Lavage, 828 

Leptandra. of great value in intestinal 
types, prescription for. 351 

Massage, 829 

Nitrate of silver, especially when an ulcer 
is present, 827 

Nitro-hydrochloric acid or nitric acid, 
valuable in many cases, 391, 395, 829 

Ox-gall, 419 

Pancreatin, with sodium bicarbonate snd 
alkaline mineral waters in intestinal 
tyDes, 421, 828 

Papain, 422 

Pepsin, immediately after meals, 426 

Podophyllin or mercury, in lientery, 829 

Prescription for flatulence of intestinal 
indigestion, 448, 828, 829 

PrescriDtion for torpid liver of indigestion, 
829 " 

Salol (phenyl salicylate), in intestinal form 
with fermentation, 470 

Serpentaria, as a tonic, 483 

Test-meal, as a means of diagnosis. 825 

Thymol, heta-naph.th.ol, creosote, chloral, 
and sodium thiosulphate in acidity due 
to acids of fermentation. 828 

Yellow oxide of mercury, gr. ^ to ^ 
(0.001-0.0012), in trituration, if there is 
foul belching or ill-smelling stools, 377 

INFLAMMATION. 

Acacia, is inflamed and irritated mucous 
membranes, 63 

Aconite, in acute, 73 

Bismuth in inflammation of mucous mem- 
branes, 147 

Cannabis, valuable in chronic types, 176 

Cocaine, in acute types, prescription for, 
228 

Cold applications, locally, 557 

Flaxseed, for inflamed mucous membranes, 
285 

Hop poultice, 304 

Liquor plumbi subacetatis, useful as a 
topical application, 349 

Opium, 414 



Silver nitrate useful in all inflammations 
of the pharynx, larynx, fauces, and 
mouth, 387 

Sulphurated lime, useful to check, 170 

Tartar emetic, in sthenic inflammation, 101 

Turpentine stupe, 524 

INFLUENZA, 829 

Aconite, sweet spirit of nitre, and citrate 
of potassium, in combination valuable 
in earlv stage, 831 

Alcohol, S33 

Antipyrine, phenacetin, and a^etanilid 
should be used only in small doses to 
allay pain, 830 

Aspirin, gr. 5 (0.3), with cinchonidine sul- 
phate,- gr. 3 (0.2), in capsule, very useful, 
830 

Barbital, barbital sodium, or sulphonal, for 
insomnia, 834 

Belladonna combined with strychnine, if 
there be vasomotor paresis. 832 

Bromides, codeine, or morphine, if cough 
be excessive, 834 

Cannabis indica, often valuable, if pushed, 
for irritative cough, 834 

Castor oil or magnesium sulphate, for con- 
stipation, 834 

Cold bath preferable to antipyretics, for 
reduction of temperature, 831 

Ergot, cannabis indica, with bromides, 
often relieve vertigo, 834 

Medinal as a sedative, 833 

Monobromated camphor, 174 

Novaspirin, 400 

Phenacetin, 70 

Remedies for bronchitis when present. 833 

Salicin. 463 

Salol (phenyl salicylate) and phenacetin, 
valuable in combination, to allay irri- 
tation and pain, 830 

Sandalwood oil for excessive cough, 471 

Steam inhalations, laden with vaporized 
drugs, for cough, 833 

Strychnine preferable to digitalis, if there 
be tendency to collapse, 832 

INSANITY. (See Mania, Acute.) 



INSOMNIA, 834 

Adalin, gr. 5 to 20. in capsule, useful in 
mild insomnia and nervous irritability, 
74 

Barbital (veronal) in nervous insomnia, 
137, 835 

Barbital sodium (veronal sodium). 137. 835 

Bath, cold, in cerebral anaemia, hot, in 
nervous irritability, 559 

Bromide of strontium or sodium with 
Fowler's solution, in nervous females, 
prescription for, 154, 835 

Chloral, useful if not due to pain, prescrip- 
tion for, 189, 835 

Chloral formamide, gr. 15 to 60 (1.0-4.0), 
in wine or capsule, in nervous insomnia, 
191, 836 

Chloralose, 2 to 8 grains (0.12-0.4), in cap- 
sule, 192 

Chloretone, 192, 836 

Chlorobrom, for insomnia of melancholia 
and acute mania, 192 



1002 



INDEX OF DfSEASES AND REMEDIES. 



Croton chloral preferable to chloral, if due 
to pain, 248 

Dionin, to fortify veronal and sulphonal, 
260 

Dormiol, a substitute for chloral, 261 

Drip-sheet in insomnia due to faulty cere- 
bral circulation or nervous tension, 562 

Duboisine more useful than hyoscine, 261 

Exercise if patient follows a sedentary life, 
836 

Hop pillow, 304 

Hot pack, in nervous insomnia, 592 

Hot-water bags to feet and cold to head, 
or general hot bath, 559, 836 

Hvoscine, gr. T J a to ^ (0.0006-0.0007). by 
mouth, or gr. ^ to ^ (0.0004-0C006), 
hvpodermically, in mania or hysteria, 
312, 313, 836 

Hypnal, useful in insomnia due to pain, 314 

Medinal (barbital sodium). 137. 835 

Morphine with chloral, if due to pain, 
prescription for, 835 

Opium, r only to be used in pain, 413 

Paraldehyde, 422, S36 

Potassium bromide in nervousness and 
overwork, 153 

Sodium bicarbonate if sleeplessness arises 
from aciditv of stomach, 837 

Somnal. m 10 to 40 (.0.6-2.5), in liquor- 
ice and water, 487 

Sulphonal, prescription for, may be given 
in hot water, 495, 835 

Trional, in 15-grain (1.0) doses, 516, 835 

Valerian, in nervousness, 526 

INTERMITTENT AND REMITTENT 
FEVER, 837 

Alcohol, contraindicatod during chill, 841 

Ammonium chloride in, 95 

Anesthetization, has been employed to put 
off paroxysm, 841 

Arsenic, in intervals between attacks, as 
an antiperiodic, 118 

Calomel, gr. 1 (0.06) every fifteen minutes 
until 5 grains (0.3) are taken, four or five 
hours before quinine, if constipation is 
present, 839 

Chloroform inhalations, preceded by lauda- 
num, bv mouth or rectum, or morphine, 
gr. £ (0*01). with atropine, gr. ^ (0.001). 
hvpodermicallv. if death threatens during 
chill, 841 

Cool drinks and sponging: in fevered stage, 
cold with friction, 841 

Digitalis or strychnine, to relieve internal 
congestion, during chill, 840 

Eupatorium, useful in, 283 

Ipecac or apomorphine, as an emetic, if 
chill follows full meal, 840 

Methylene-blue, 1 to 4 grains (0.06-0.25 
381 

Podophyllin. gr. ^ to | (0.006-0.008), pre- 
ceding quinine, if constipation is present, 
839 

Quinine, as a prophylactic and antiperiodic, 
838, 839. 840 

Salvarsan, 840 

INTERTRIGO. (See Chapping.) 

INVOLUTION (ANOMALIES OF), 893 

Applications of nitric acid and silver nitrate 
useful in lacerations, 894 



Cannabis indica of great value in subinvolu- 
tion, 176 

Cimicifuga in subinvolution, 214 

Curette in subinvolution due to retention 
of hypertrophic endometrium, 894 

Digitalis in subinvolution due to sluggish 
circulation, 894 

Ergotin, gr. 1 (0.06), hydrastifiin, gr. § 
(0.03), and stypticin, gr. 1 (0.06), in pill, 
if due to fibroids, 264, 894 

Pituitrin (1 c.c. of 20 per cent, solution) is 
declared to be the strongest stimulant to 
uterine contraction, 894 

Purgatives, disinfectants, and possiblv hot 
water locally applied, if due to inflam- 
mation, 894 

Removal of placenta, if adherent, 894 

IRITIS, 842 

Atropine, the best local remedy, 142, 843 

Counterirritation, 575 

Daturine, scopolamine, or duboisine, when 

atropine cannot be used, 843 
Dionin, 5 per cent, solution, locally, for 

pain, 844 
Holocaine as a local anaesthetic, 303, 844 
Hyoscine valuable for pain, 313. 844 
feed compress, in early stage of traumatic 

iritis, 843 
Iodide of potassium, alone or with mercury 

bichloride, following mercurial impres- 
sion, in syphilitics, 844 
Iridectomy required in some cases, 844 
Leeches and dry heat or hot fomentations. 

to relieve pain, 586. 843 
Mercury, preferably by inunction, if due 

to syphilis, 844 
Morphine, if pain is severe, 844 
Neisser's bacterin in gonorrheal iritis, 84.4 
Paracentesis, 843 
Pilocarpine, internally, if vitreous becomes 

opaque, also in gonorrhceal types. 843 
Salievlate of sodium, or aspirin, in full dose, 

in rheumatic iritis, 844 
Salvarsan and neosalvarsan in syphilitic 

iritis. 844 
Scopolamine in early stages of, and in 

plastic, 3.13, 477 
Subconjunctival injections of cvanide of 

mercury (1 : 5000-1 : 1000), or of salt. 

solution recommended in syphilitic iritis, 

843 
Tuberculin recommended in iritis due to 

tuberculosis, 843 
Vaccines, autogenous, have given admirable 

results in certain forms, S44 

IRRITABILITY. 

Adalin useful, 74 

Almonds, as a drink in irritability of intes- 
tines and air-passages, 84 

Buchu in chronic vesical irritability, 160 

Cantharis, recommended in irritable blad- 
der of women and children, 178 

Cimicifuga, in uterine irritability, 214 

Hops, in vesical irritability, 304 

Hydrocyanic acid, in irritability of the 
stomach, 308 

Hyoscyamus, for vesical irritability with 
incontinence, 312 

Milk of magnesia in gastric irritability and 
acidity of adults and children, 357 



INDEX OF DISEASES AND REMEDIES. 



1003 



Petrolatum, as a soothing agent in gastro- 
intestinal types, 428 

Piperazine, in bladder irritation due to 
excess of uric acid, 444 

Potassium bromide, in irritability of the 
pharynx, 153 

Salicylates with bromides in nervous irri- 
tability of gouty or lithsemic persons, 46G 

Urotropin in irritability due to alkaline 
urine, 301 

JAUNDICE. 

Calomel, gr. f (0.01) every half-hour until 

gr. \ (0.C3) is taken, if due to cold. 373 
Carbolic acid (phenol), gr. 10 (0.6), with 
water and glycerin, each 2 drachms 
(8.0), locally applied in itching of jaun- 
dice, 432 
Citric acid, in catarrhal form. 225 
Hydrastis, useful in subacute types, 305 
Iodoform, highly recommended, 327 
Manganese sulphate, may be tried in 

malarial types, 359 
Pilocarpine, useful unless due to malignant 

disease, 442 
Salol, said to be of value, 470 
Sanguinaria of service, 472 
Sodium phosphate of value, 485 

JOINTS (ENLARGED). 

Counterirritation. 575 

Leeches to swollen joints after sprains, 614 
Tartar emetic ointment as a counter- 
irritant in old enlargements, 102 
Turpentine liniment, 525 

JOINTS (INFLAMED). 

Alcohol, locally, as a wash, 79 
Camphor liniment, locally, 172 
Mustard to allay pain, 383 
Sodium salicylate or bicarbonate solution 
to inflamed rheumatic joints. 467, 483 

JOINTS (RHEUMATIC). 

Oil of amber as a counterirritant over, 88 
Oil of gaultheria in acute and chronic rheu- 
matic joints, 290 
Phylacogens, 623 
Salicylic acid ointment useful, 467 
Veratrine ointment, 528 

KELODD. 

Ichthyol ointment, 315 

Thiosinamine, 10 per cent, solution in 
alcohol, injected into the growth, 510 

KERATITIS (INTERSTITIAL), 845 

Antiseptic lotions, in marked ciliary con- 
gestion, 845 

Antisyphilitic treatment, if due to syphilis, 
845 

Atropine, in ciliary congestion, to prevent 
iritis, 845 

Diet and hygiene, 845 

Dionin valuable in 1 to 5 per cent, solutions, 
260, 845 

Leeches to temple to relieve pain, if patient 
is not too young for bleeding, 845 



Salvarsan and neosalvarsan, 845 
Thymol iodide, as a dusting-powder, 512 
Tuberculin efficacious in tuberculous cases, 
845 

KERATITIS (PHLYCTENULAR), 845 

Atropine, to relieve pain, 846 

Boric acid solution, to relieve congestion, 

846 
Cocaine, not advisable in photophobia, 846 
Cold-water douche on closed eyelid, to 

relieve photophobia, 846 
Creolin solution, 1 to 2 per cent., as a wash, 

245 
Dark glasses, to protect eyes, 846 
Holocain solution, 2 per cent., to relieve 

pain, 303, 846 
Tonics and alteratives, with strict hygiene 

and regulated diet, associated with locai 

treatment, 846 
Yellow oxide of mercury ointment, or 

calomel as a dusting-powder, to hasten 

cicatrization, contraindicated if iodine is 

being given, 846 

KERATITIS (ULCERATP7E), 846 

Antidiphtheritic serum, 848 
Antipneumococcus serum, 3 to 5 c.c, sub- 

cutaneously in ulcers due to pneumo- 

coccus infection, 848 
Antiseptic lotions, to limit sloughing, 847 
Atropine, instilled into eve, to limit slough- 
ing, 847 
Cautery, actual, best means of preventing 

perforation, 848 
Curetting floor of ulcer, if perforation 

threatens, 848 
Dionin of service in corneal infiltration of 

recent origin. 847 
Dionin valuable in 1 to 5 per cent, solutions 

260. 847 
Eserine ; instilled into eye, in peripheral 

ulcers, 847 
Holocaine as an anaesthetic, 303, 848 
Hot compresses, 586, 847 
Massage of cornea and introduction of 

vellow oxide ointment to remove scars 

of ulcers, 848 
Paracentesis, 847 
Pressure bandage, if perforation threatens. 

848 
Silver nitrate, tincture of iodine, or for- 
maldehyde applied to margin of ulcer 

does good, 848 
Subconjunctival injections of cyanide of 

mercury (1 : 5000) or of salt solution to 

absorb corneal nebula, 848 

LACHRYMAL ABSCESS, 849 

Division of canaliculi and washing out sac 
with antiseptic fluids, and insertion of 
probes into ducts after inflammation 
subsides, to restore patulency, 849 

Formaldehyde (1 : 6000), silver nitrate 
(1 500), or protargol or argyrol (2 to 
5 per 100), injected through external 
opening if there is purulent discharge, 
849 

Hot compresses, composed of lead-water 
and laudanum, to relieve pain, 850 

Puncture of abscess, if rupture threatens, 
849 



1004 



INDEX OF DISEASES AND REMEDIES. 



LARYNGISMUS STRIDULUS. 

Amyl nitrite, 98 
Belladonna, 142 
Bromide of potassium, 154 
Gelsemium. 291 



LARYNGITIS (ACUTE), 850 

Aconite to control fever. 851 

Antipyrine, as a spray, 107 

Bromides, useful in full doses, 60 to 120 

grains (.4.0-8.0) a day, 153 
Calomel, small and repeated doses, followed 

by saline purges, along with hot mustard 

foot-baths and demulcent drinks, 851 
Creosote spray in subacute laryngitis, 247 
Cubeb cigarettes, useful for hoarseness of 

subacute forms, 249 
Inhalations in, 603 
Iodine, painted over throat, useful on third 

or fourth day, 851 
Iodol, 328 
Mustard plaster or hot applications over 

larynx, 850 
Nitric acid, dilute, 1U 2 to 3 every half-hour 

or hour for six doses in early stage, 851 
Oil of amber and olive oil, half and half, 

well rubbed into the skin of the neck 

and chest. 99, 851 
Prescriptions for spravs, 850 
Silver nitrate. 389 
Steam inhalations, charged with benzoin; 

often advantageous to add menthol, 145, 

603. 850 



LEPRA. 



Arsenic, 118 



LEUCOCYTHJEMIA. 

Arsenic, very useful in full ascending doses. 
116 

LEUCORRHCEA, 851 

Alum, gr. 10 to 20 to the ounce (0.6-1.3 : 

30.0), as a vaginal wash. 87 
Ammonio-ferric alum, gr. 2 to 5 (0.12-0.3) 

in atonic tvpes. 333 
Belladonna, gr. 1 to 2 (0.06-0.12). with 

tannic acid, gr. 6 to 8 (0.4-0.5), applied 

with cotton, in disease of uterine cervix, 

141 
Cantharidal collodion, applied over groins 

to produce blister, 852 
Goodell's prescription for, 852 
Hsematoxylon, used internally, of service, 

299 : 
Hot sitz-bath, or vaginal injections of hot 

water, if due to uterine congestion, 587 
Hydrastis, injections, 305 
Iron, with tonics, if due to excessive lacta- 
tion or exhausting life, 852 
Myrrh, if due to uterine trouble, 384 
Nitrate of silver, when there is cervical 

ulceration, 389 
Potassium permanganate (drachm \ [2.0] 

to water 1 pint [480.0]), as an injection, 

if discharge is fetid, 853 
Prescriptions for injection, 853 
Ringer's prescription for wash, 853 
Tampon, saturated with iodoform and 

tannic acid, 505, 853 



White oak bark (ounce 1 [30.0] to water 1 
pint [480.0]), or tannic acid and glycerin 
(ounce 1 [30.0] to 2 quarts [2 litres] of 
water), as an injection, 458, 853 

LEUKEMIA. 

Atoxyl valuable in, 135 
Oxygen inhalations, 419 

LICHEN. 

Arsenic, usually cures, 118 
Cantharides, 178 

Carbolic acid (phenol) ointment in lichen 
planus, 432 

LID ABSCESSES, 853 

Treatment same as for other abscesses, 854 

LITILffiMIA. (See Gout,) 

LOCOMOTOR ATAXIA. 

Acetanilid, 67 

Antipyrine relieves lancinating pains,- 107 

Arsphenamine (salvarsan), serum, 128 

Chloralformamide, prescription lor, 191 

Co-ordinated movements in, 571 

Exalgine, prescription for, 285 

Phenacetin, 70 

Potassium bromide., to prevent laryngeal 

crises, 153 
Salvarsanized serum. 129 

LUMBAGO, 854 

Acupuncture, often relieves, especially if 
pain is bilateral. 535. 854 

Antifebrin. dose. gr. 2 to 4 (0.12-0.25), 854 

Antipyrine, dose, gr. 5 to 10 (0.3-0.6). 854 

Capsicum plaster useful, 180 

Chloroform liniment. 208 

Cod-liver oil, 234 

Ether or ethyl chloride spray locally, 854 

Foot-bath and Dover's powder, before 
retiring, often relieves, 854 

Hot poultice to back often useful, 854 

Ice-bag or ether spray to loins, if hot appli- 
cations fail, 854 

Ironing back with laundry iron, skin being 
protected by cloth or paper, very effi- 
cient, 586, 854 

Monobromated camphor, with other drugs, 
very useful, 173 

Mustard or capsicum plaster or blister over 
painful spot may relieve, 854 

Phenacetin and salol, of each 5 grains (0.3), 
854 

Potassium iodide or salicylic acid, if recov- 
ery is slow, 318, 854 

Salicylic acid, useful, 466, 854 _ 

Strapping often relieves sacro-iliac pain, 854 

Turpentine, gtt. 20 (1.3), said to be useful, 
525 

LUPUS. 

Acid nitrate of mercury, 376 
Carbon-dioxide snow in lupus erythemato- 
sus, 556 
Europhen, in ointment or powder, 284 
Ichthyol ointment, 315 
Iodine, as a paint, to retard spread, 323 
Thiosinamine, useful in, 510 



INDEX OF DISEASES AND REMEDIES. 



1005 



MALARIAL FEVER. (See Intermit- 
tent and Remittent Fevers.) 

Antipyrine, 107 

Arsenic, as a cure and prophylactic, 115, 

118 
Arsphenamine (salvarsan) useful, 127 
Calomel, 367 
Eucalyptus, instead of quinine, when it 

cannot be borne, 282 
Gelsemium, of doubtful value, 291 
Gentian, in malaria associated with dys- 
pepsia, 292 
Hydrastis, said to be antimalarial, 305 
Methylene-blue, 1 to 4 grains (0.05-0.2). 381 
Pilocarpine, may be used to abort, 442 
Quinine, the best remedy as a prophylactic 

and a cure, 217 
Warburg's tincture, said to excel quinine 
in pernicious malariai regions, 530 



MALARIAL FEVER (PERNICIOUS), 

841 

Morphine and atropine, hypodermically, 
to control retching and vomiting, 841 

Quinine, 10 to 15 grains, intravenously, 841 ; 
must be used with great caution in hema- 
turic or hemoglobinuric type, and not at 
all unless the malarial organism can be 
found in the blood, 841 

Sodium thiosulphate, 60 grains every two 
or three hours, in malaria hematuria, 841 

Water, copiously, with or without lemon 
juice, to flush the kidneys, 841 

MANIA (ACUTE), 854 

Anaesthetics, or apomorphine in emetio 
dose, to relax muscular system, if patient 
is very violent, so that other remedies 
may be administered, 855 

Bromide of potassium, as a soporific, 154 

Cannabis indica, with large doses of bro- 
mides, particularly serviceable, 854 

Chloral, in full doses, if kidneys are healthy, 
854 

Cold douche to head while body is im- 
mersed in hot water, often of service, 855 

Duboisine, for insomnia, 261 

Hot-steam bath or Russian bath valuable, 
855 

Hyoscine hydrobromide, gr. T ^ (0.0006), 
when necessary to quiet patient quickly, 
312, 854 

Morphine, in full dose, may be required to 
quiet patient, 855 

Sulphonal as a hypnotic, 495 

Thyroid gland, gr. 5 to 20 1.0.3-1.3), 514 

MARASMUS. 

Cod-liver oil inunctions, one of the best 

remedies, 234 
Mercury with chalk in syphilitic marasmus, 

375 

MASTITIS. (See Breast, Inflamed.) 

MELANCHOLIA, 855 

Nitro-muriatic acid, TTj. 5 (0.3), in water 
after meals, if associated with oxaluria, 
395, 855 



Phosphorus, useful in some cases due to 

overwork, 437 
Thyroid gland, gr. 5 to 20 (0.3-1.3), 514 

MENINGITIS (ACUTE), 855 

Alcohol, given with food in second stage, 

if there be asthenia, 856 
Antimeningitis serum is only remedy of 

real value, 548. 855 
Blister to nape of neck, in early stage, to 

prevent effusion, also in comatose state, 

856 
Bromides and chloral, best agents to allay 

nervous symptoms, 856 
Ice-bag to head, in early stage, 559, 855 
Leeches to nape of neck, in earlv stage. 613, 

855 
Lumbar puncture, if symptoms of cerebral 

pressure are marked, 615, 856 
Milk diet, in second stage, 856 
Opium, useful in second stage, 413 
Quinine, contraindicated in acute stage, 856 
Venesection in early stage of sthenic cases, 

if aconitiue or veratrum viride is not at 

hand, 637 



MENINGITIS (CHRONIC). 

Phosphorus, 437 

MENOPAUSE. 

Bromide of potassium, in nervous disorders, 
153 

Cannabis indica, alone or with aloes and 
iron, if anaemia or constipation exist in 
headaches of the menopause, 176 

Eau de Cologne, saturated with camphor, 
locally applied in headache or drowsi- 
ness, 173 

Ovarian extract, for nervous and nutri- 
tional disturbances, 293, 419 

Valerate of ammonium, in nervous dis- 
orders, 96 

MENORRHAGIA AND METROR- 
RHAGIA, 813 

Adrenalin chloride (1 : 5000) may be em- 
ployed, 501, 814 

Bromide of potassium or sodium, gr. 10 
(0.6) once or twice daily, if bleeding is 
irregular, 154, 814 

Cannabis indica, recommended, 176, 814 

Cinnamon oil, drachm h (2.0), when erig- 
eron is not at hand, in oozing flow, 814 

Cotarnine useful, 245, 814 

Dry cups over sacrum, if due to conges- 
tion, 814 

Ergot, fluidextract, Til. 10 to 60 (0.6-4.0), 
best remedy in active bleeding, 264, 814 

Erigeron, oil of, Til 3 to 5 (0.2-0.3), in 
capsule or emulsion, the best remedy 
for oozing, 265, 814 

Hamamelis, water of, drachm 1 (4.0) thrice 
daily, in irregular bleeding, 814 

Monsel's solution (50 per cent.), full 
strength locally applied if due to poly- 
pus, 337 

Rhus aromatica, highly recommended in 
menorrhagia, 461 

Rue, in atonic menorrhagia, 462 



1006 



INDEX OF DISEASES AND REMEDIES. 



Savine, oil of, TT1.5 to 10 (0.3-0.6), in cap- 
sule or emulsion, every three or four 
hours, as a tonic in menorrhagia, 474 

Turpentine, often of value, 525 

MENSTRUATION. 

Corpus luteum seems to do good in scanty 

menstruation, 244 
Rest cure in disorders of menstruation, 626 
Suppression of, due to cold, aconite iu, 73 
Turkish bath, 588 

MIGRAINE, 856 

Ammonium benzoate, gr. 10 to 20 (0.06- 

1.3), 857 
Amy! nitrate, 98 

Bromide of potassium, with caffeine, al- 
most a specific, if due to eye-strain. 154 
Cannabis indica, extract, gr. | to h (0.015 

0.03). with tincture of gelsemium. gtt. 10 

to 20 (0.6-1.3), every two hours", 175. 

856 
Corpus luteum in menstrual migraine, 244 
Croton chloral, very efficient, especially if 

fifth nerve is involved, 248 
Gelsemium, with cannabis indica, to abort, 

291, 856 
Menthol pencil useful externally. 425 
Methylene-blue, gr. 1 to 2 (0.06-0.12), in 

capsule, 381 
Phenacetin, 70 

Rachford's prescription for, 856 
Salicylic acid, of great service in rheumatic 

types, 466 ; 857 
Sodium phosphate, in hot water taken in 

morning, 856 
Starr's prescription for, 857 

MILK DEFICIENCY, 896 

Bier's cups, to produce local hyperemia, 

have proved efficient, 897 
Electricity, 896 
Pituitrin, 897 

Placental extract under trial. 897 
Treatment for intercurrent affection, if due 

to such cause, 896 

MORPHIOMANIA. (See Poisoning 
from Opium, Chronic.) 

Bromide of potassium, 154 
Hyoscine, in full dose. 313 
Phosphorus, of service in sequelae of mor- 
phiomania, 437 

MUCOUS MEMBRANE (DISEASES 
OF). 

Acacia, as a mucilaginous drink in irrita- 
tion and inflammation of upper air 
passages, 63 

Bismuth, as an astringent, to inflamed 
membranes, 147 

Flaxseed, as a soothing demulcent, 285 

Glycerole of aloes, locally applied to fis- 
sures, valuable, 86 

Opium, suppositories, gr. \ (0.015), useful 
in rectal inflammation, if not an acute 
catarrh, 413 

Pareira, useful in chronic genito-urinary 
inflammation, 423 



Tannic acid, useful in depressed conditions, 
505 

Terebene, useful in subacute and chronic 
genito-urinary inflammation, instead of 
sandalwood or copaiba, 507 

Zinc sulphate, weak solution, as an astrin- 
gent, 533 

MUSCtf! VOLITANTES, 857 

Alteratives and correction of anomalies of 
refraction, 857 

MUSCULAR STIFFNESS. 

Hot laundry iron passed over part, skin 
being protected by layers of paper or 
cloth, often relieves. 586 

MYALGIA, 858 

Ammonium chloride, if due to cold or 

bruises, 858 
Cnmphor liniment, 172 
Chloroform liniment, 858 
Cimicifuga. fluidextract, Tl\ 20 to 1 drachm 

(1.3-4.0). 858 
Clove oil, added to liniment, as a counter- 
irritant, 226 
Iodide of potassium or salicylates, if due 

to rheumatism, 858 
Iodine ointment, pure or diluted with lard, 

858 
Massage or good rubbing, very necessary, 

858 
Potassium acetate or citrate, gr. 20 (1.3), 

may be tried. 858 
Poultices, hot as can be borne, 858 
Prescription for liniment, 858 

MYXCEDEMA. 

Thvroid gland, or extract of , a specific for, 
513 

NASAL CATARRH (ATROPHIC), 858 

Dobell's solution, as a cleansing wash; 
carbolic acid may be increased, or 
thymol and eucalyptus substituted for 
it, to relieve odor, 149, 859 

Galvano-cautery, or strong silver nitrate 
solution, if ulcerations are present, 859 

Hydrogen peroxide, 859 

Ichthyol, useful, 859 

Iodine and glycerin (gr. 6 to 8 to the ounce 
[0.4-0.5:30.0]), with potassium iodide, 
sufficient to cause solution of the iodine, 
valuable locally applied, 860 

Potassium iodide internally, tonics and 
stimulants to mucous membrane, and 
attention to activity of skin, 860 

Potassium permanganate, useful; painful 
if sensation is not entirely lost, 859 

Removal of necrosed bone, 859 

Silver nitrate and starch (gr. 1 to 10 [0.06- 
0.6] to drachms 2h [10.0]), as an insuf- 
flation powder, or solution (gr. 1 to 10 
to the ounce [0.06-0.6 : 30.0]), better 
in some cases, locally applied, 859 

NASAL CATARRH (CHRONIC), 860 

Alkaline wash, 860 
Arsenic, 118 



INDEX OF DISEASES AND REMEDIES. 



1007 



Camphor, 172 

Ferric alum (gr. 5 to the ounce [0.3 : 30.0]), 
useful, in spray, in later stage, 861 

Galvano-cautery or snare, to remove hyper- 
trophic tissue remaining after acute 
stage, 861 

Hydrastis, dilute solution or distilled 
extract of hamamelis and water, equal 
parts, useful in spray, in acute stage, 
305, 861 

Iodine and glycerine (gr. 6 to 8 to the ounce 
[0.4-0.6 : 30.0]), with potassium iodide, 
sufficient to cause solution of the iodine 
locally applied, 861 



NAUSEA. (See Vomiting.) 

Hoffmann's anodyne, when due to excessive 
use of tobacco, 302 

Hydrocyanic acid, dilute, 1U 3 (0.2), in 
water, often useful, 309 

Lime-water, 168 

Seidlitz powder, when associated with con- 
stipation, 478 



NEPHRITIS (ACUTE), 861 

Aconite, to depress circulation, 861 

Blisters contraindicated, 861 

Bromides or opium, given cautiously, if 

aconite fails to quiet restlessness, 861 
Caffeine, in later stages, 862 
Cannabis indica, if hsematuria is present, 

also to allay pain over kidney, 176, 861 
Cantharides, | to 1 HI (0.03-0.06) of 

tincture about fifth day, when kidneys 

are atonic, also if hsematuria is present, 

178, 861 
Citrate of potassium and sweet spirit of 

nitre, to increase flow of urine, 862 
Cups or leeches over loins if urine is scanty, 

861 
Digitalis with squill or calomel, gradually 

increased, followed by gin or compound 

spirit of juniper in later stages, 862 
Elaterium, to relieve dropsy, 862 
Flaxseed tea, as a demulcent, 285, 862 
Gallic acid and ergot to control excessive 

hsematuria, 862 
Hot-air baths, useful to provoke sweat, 862 
Iron, if ansemia be present, also to decrease 

albuminuria, 862 
Juniper, to re-establish secretion, after 

inflammation has subsided, 341, 862 
Milk diet, 861 
Pilocarpine hydrochloride, gr. ^ to f- 

(0.003-0.008), hypodermically, if ursemia 

threatens, repeated in fifteen minutes 

if no sweat appears, but guarded by 

strychnine when the heart is weak, 442, 

862 
Potassium bitartrate, 451 
Sulphate of magnesium, §ss (16.0), or 

calomel, to aid in elimination of toxic 

products by bowel, 862 
Turkish bath, to aid in eliminating effete 

products, used with care, 588 

NEPHRITIS (CHRONIC), 862 

Basham's mixture for ansemia, 334, 864 
Bichloride and protiodide of mercuiy, 370, 
377 



Cannabis indica, to allay pain over kidneys, 
also if hsematuria is present, 176 

Cantharides, particularly useful if due to 
alcoholism, 178, 863 

Capsicum, to check albuminuria, 180 

Chloride of gold and sodium have been 
recommended in interstitial forms, 295 

Chloride of iron if ansemia is present; also 
to decrease albuminuria, 335, 864 

Digitalis and caffeine useful, 256, 863 

Elaterium or jalap, to relieve dropsy, 863 

Juniper of value, 341, 863 

Methylene-blue solution hypodermically, 
when kidney is suspected of being inade- 
quate, 380, 864 

Milk diet, 863 

Nitroglycerin useful in ascending doses in 
chronic parenchymatous nephritis, 393, 
863 

Oxygen inhalations, 864 

Potassium acetate or bitartrate combined 
with digitalis, or the bitartrate combined 
with gin or compound infusion of juniper, 
451, 863 

Potassium iodide, gr. 5 (0.3) thrice daily, 
used with great care, 318 

Protoiodide of mercury useful, 377 

Sodium iodide of great value in many 
cases, 863 

Squill, 488, 863 

Strontium lactate, for the relief of albu- 
minuria, 492 



NEPHRITIS (INTERSTITIAL). 

Nitroglycerin, with cardiac disturbance and 
high arterial tension, 393 



NERVOUSNESS. 

Ammonium valerate in nervous unrest of 
pregnancy, or hysteria, 96 

Asafcetida in nervous irritability of chil- 
dren, 133 

Bromides, 153 

Camphor, as a sedative, 171 

Corpus luteum in nervous disturbances 
during artificial menopause, 244 

Hops, as a sedative, 304 

Lecithin used when there is nervous exhaus- 
tion, 350 

Musk useful in nervous excitement and col- 
lapse, only to be used through crisis, 383 

Phosphorus, in nervous debility and ex- 
haustion, 437 

"Pill of three valerianates," highly recom- 
mended, 527 

Rest-cure very useful where nervousness 
is due to exhaustion, 626 

Strychnine, in functional nervous atony or 
depression, 402 

Sumbul, prescription for, 499 

Suprarenal gland, 500 

Sweet spirit of nitre, in nervous excite- 
ment of fever and other nervous states of 
infancy, 503 

Valerian, alone or with other drugs, 526 



NEURALGIA, 864 

Acetanilid useful especially with mono- 
bromated camphor, 67, 865 



1008 



INDEX OF DISEASES AND REMEDIES. 



Aconite ointment (gr. 2 to the drachm 
[0.12 : 4.0]), or oleate of aconitine (gr. 2 
[0.12] to sweet oil 100 minims [6.6]), use- 
ful applied over painful spot, if limited in 
area, 73 

Acupuncture, nerve-stretching, or neurec- 
tomy, necessary in some cases, 867 

Alcohol, 90 per cent., with 4 gr. (0.24) of 
cocaine to the ounce (30.0), injected 
locally in quantities of 15 to 30 minims 
(1.0-2.0), 866 

Ammonium chloride, in ovarian neuralgia, 
95 

Amyl nitrite, inhalations, when due to 
anaemia, 866 

Antipyrine very useful, especially in gout, 
rheumatism, or nervous depression, 106, 
865 

Aspirin, 5 to 20 grains (0.3-1.3), in tablet 
or capsule, is very efficacious, 135, 865 

Belladonna, 141, 143 

Bromide of potassium with caffeine, almost 
a specific, 154, 865 

Camphor liniment, locally applied, to 
relieve pain, 172 

Castor oil, oz. 1 to 2 (30.0-60.0) a day, at 
times gives good results, 866 

Chloral formamide, 191 

Chloral locally, prescription for, 190 

Chloretone and antipyrine (3 to 6 grains 
[0.2-0.4]), 193 

Chloroform by kataphoresis, 867 

Chloroform liniment, as a local anaesthetic, 
208 

Cimicifuga, especially useful in ovarian 
types, 214 

Cod-liver oil, 234, 864 

Cold applications, locallv, 558 866 

Croton chloral, gr. 5 to 20 (0.3-1.3) in 5- 
grain pills, often effective in brow 
neuralgia, 248, 866 

Duquesnel's crystalline aconitine in obsti- 
nate forms. 74 

Freezing parts with ether or rhigolene 
spray or by small packages of ice and 
salt," 275, 559,866 

Guaiacol used locally of value, 298 

Hydrocyanic acid useful in intestinal neu- 
ralgia, 309 

Iodide of potassium, may be tried in rheu- 
matic neuralgia, 318 

Iron and arsenic, in anaemia; often neces- 
sary to associate with them bitter tonics 
and cod-liver oil, 864 

Kataphoresis, 867 

Magnesium sulphate solution locally, 358 

Menthol locally, 425. 866 

Morphine, gr. J to | (0.012-0.015), injected 
into painful spot, if localized; not advis- 
able in chronic cases, 867 

Muriate of ammonium, useful in ovarian 
types, 94 

Mustard plaster, as a counterirritant, 383 

Novaspirin, 400 

Nux vomica or strychnine, if nerve is de- 
pressed by anaemia, 865 

Peppermint oil, locally applied on cloth 
over painful spot, 424 

Phenacetin, gr. 3 to 8 (0.2-0.5), very use- 
ful, prescription for, 69, 865 

Phenocoll, 428 

Phosphorus, if due to nervous exhaustion, 
437, 865 

Potassium iodide, 318 



Prescriptions containing antipyrine with 
bromides and caffeine, 154, 866 

Quinine, if due to malaria, 865 

Rest-cure very useful in exhausted patients, 
626 

Salol (phenyl salicylate), if due to exposure, 
470 

Salophen, useful when combined with 
phenacetin, 471 

Specific remedies, if due to scrofulosis or 
syphilis, 865 

Turkish baths, may relieve if due to rheu- 
matism or gout, 588 

Veratrine ointment, locally applied, over 
neuralgic nerve, 528 

NIGHT-SCREAMING. 

Bromide of potassium, 154 

NIGHT-SWEATS. 

Acetic acid, as a lotion, diluted one-half, 68 

Agaricin, of doubtful value, 75 

Alum dissolved in water or alcohol, effi- 
cient application for sponging, 87 

Belladonna, one of the most powerful 
remedies we have, 141 

Camphoric add, the best of all remedies, 
174 

Ergot, 264 

Euformol as a lotion, 287 

Gallic acid, 288 

Pilocarpine, gr. 20 (0.003), hypodermically, 
two hours before sweat, often useful, 
even when atropine fails, 443 

Sulphuric acid, with belladonna or mor- 
phine, often useful, 499 

Zinc oxide, prescription for, 533 

NIPPLES (SORE), 867 

Benzoin, tincture, locally applied, 868 
Boric acid (gr. 20 to the ounce [1.3 : 30.0]), 

or mucilage of acacia, applied after 

nursing, nipple being dried beforehand, 

867 
Breast-pump or nipple-shield may be 

necessary to effect cure, 868 
Cocaine (gr. 4 to the ounce [0.25 : 30.0]), 

applied and washed off before nursing, 

if breast is very painful, 228, 867 
Ichthyol, when indurated, 315 
Prophylaxis, 868 
Silver-nitrate stick touched to fissure, if 

deep and slow to heal, 868 
Tannin, glycerite of, locally applied, 868 

NYMPHOMANIA. 

Bromide of potassium, of great service, 153 
OBESITY, 868 

Acetic acid, harmful, 68 

Cold bath, 871 

Diet, 868, 870 

Laxative fruits and purges, to regulate 

bowels, 871 
Massage, passive movements, absolute 

skimmed-milk diet, and electricity, if 

exercise is impracticable, 871 
Potassium permanganate, 427 
Saline purges, 871 
Thyroid gland, 513, 871 



INDEX OF DISEASES AND REMEDIES. 



1009 



OPHTHALMIA. (See Conjunctivitis.) 

OPHTHALMIA (SYMPATHETIC), 871 

Aspirin in large doses, 872 

Atophan, 40 to 60 grains daily, and benzo- 
salin in full dose have been recommended, 
872 .... 

Atropine, unless there is a rise in tension, 

871 . ,, 

Mercury internally or by inunction should 

be tried, 871 ...... , 

Preventive enucleation of originally injured 

eye, if treatment is unavailing, 872 
Salvarsan and neosalvarsan have been 

used with good effect, 872 
Sodium salicylate, in very large doses, 

does most good, 871 

OPIUM HABIT. (See Poisoning 
from Opium, Chronic.) 

OPTIC NEURITIS AND OPTIC 
NERVE ATROPHY, 663 

Bromide of potassium, 663 
Fly blisters to temple in some cases, 663 
Iodide of potassium, silver nitrate, phos- 
phorus, arsenic, iron, santonin, lactate of 
zinc, antipyrine and injections of organic 
liquids, all of doubtful value, 66-1 
Salvarsanized serum of value intraspinally 

in tabetic atrophy if used early, 664 
Sinusoidal current recommended, 664 
Strychru.De, in full doses, enforced by nitro- 
glycerin or inhalation of amyl nitrite, 664 
Negative galvanism has been advised, 664 
High-frequency currents should be tried, 664 
Radium and Rontgen rays have not 

proved useful, 664 
Trephining to relieve intracranial pressure, 
663 



ORCHITIS. (See Epididymitis.) 

OSTEOMALACIA. 

Corpus luteum in, 293 
Phosphorus, 437 

OTITIS MEDIA. (See Earache.) 

Dermatol as a dusting-powder in purulent 

forms, 146 
Potassium permanganate, gr. 1 to oz. 1 

(0.06-30.0), as a wash, 427 

OTORRHCEA. 

Creolin solution (1 : 500), used with 
syringe, 245 

OXALURIA. 

Nitric acid, 391 
Nitro-hydro chloric acid, 395 

OZiENA. 

Ichthyol very useful in fetid ozsena, 315 
Prescriptions for insufflation powder, 368 
Scarlet red, 475 

64 



PARALYSIS AGITANS. 

Cannabis indica, to quiet tremors, 176 
Chloral, of great service, 190 
Duboisine sulphate of some use, 261 
Parathyroid gland, 423 
Sparteine, 476 

PARASITES. 

Bichloride of mercury (gr. 2 [0.12] to water 
oz. 1 [30.0]), applied thrice daily in para- 
sitic skin diseases, 371 

Cajuput oil, applied pure, will destroy 
pediculi, 164 

Chrysarobin, gr. f (0.008), internally, or 
the ointment, with benzoated lard (1 : 4 
or 5), locally applied, in parasitic skin 
diseases; must not be used on face, 212 

Mercurial ointment, useful to destroy 
pediculus pubis or other parasites, 376 

Oil of cloves, 226 

Pyrogallol, 30 grains to the ounce (2.0 : 
30.0), for parasitic skin disease of pso- 
riasis, 457 

Thiosulphate of sodium, 1 drachm to the 
ounce (4.0 : 30.0), for parasitic skin dis- 
ease, 486 

Volatile or fixed oils, useful to destroy, 376 

PARTURITION. 

Antipyrine for pains, of doubtful value, 107 
Castor oil, to relieve constipation, 184 
Chloroform, 203 

Quinine, as a stimulant to uterus, 219 
Scopolamine and morphine to relieve pains, 
477 

PEMPHIGUS. 

Arsenic, 118 

PERICARDITIS, 872 

Aconite, to allay inflammation and quiet 
heart, 73 

Alcohol, digitalis, or caffeine, if heart shows 
signs of failure, 872 

Aspiration, gradual, if exudation endangers 
life, 872 

Blister, over the praBcordium, often useful, 
872 

Cardiolysis, when adhesions interfere with 
heart action, 872 

Elaterium, useful in effusions, 261 

Ice-bag over the praecordium, very useful, 
558, 872 

Iodide of potassium, to aid in absorption 
of fluid, 318 

Leeches, 5 to 10, over praecordium, accom- 
panied by large dose of veratrum viride 
in early stages of sthenic cases, 872 

Opium, to allay inflammation, 413 

PERITONITIS (ACUTE), 873 

Acetanilid, gr. 2 (0.12), every two or three 

hours, with brandy and ice, for vomiting, 

875 
Counterirritation, 577 
Enteroclysis, 876 
Ice for thirst. Vomiting does not contra- 

indicate small amounts of water, 875 
Ice-bag or turpentine stupe to abdomen; 

leeches in sthenic cases, 875 



1010 



INDEX OF DISEASES AND REMEDIES. 



Lavage, gastric, often advantageous, 875 

Murphy drip in post-operative or septic 
peritonitis, 875, 876 

Opium, pushed until pain is relieved, but 
never to the point of obtunding intelli- 
gence, 413, 875 

Rectal tube, milk of asafcetida or turpen- 
tine injections, in tympanites, 877 

Salines, useful in cases following surgical 
operations, but contraindicated by feeble- 
ness, perforation, or obstruction, 877 

Surgical procedures, often necessary; when 
diagnosis is obscure or in septic general 
peritonitis exploratory incision is justi- 
fied, 874 

PERITONITIS (CHRONIC), 877 

Incision, with or without drainage and 
iodoform useful in tubercular peritonitis, 
877 

PERNICIOUS MALARIAL FEVER, 841 

Morphine and atropine to control retching 

and vomiting, 841 
Quinine, large doses, in solution, by mouth, 

rectum, or hypodermically, 218, 841 
Thiosulphate of sodium, gr. 60 (4.0), to 

move the bowels, 841 

PHARYNGITIS. 

Antipyrine, in 4 per cent, spray, 107 
Cocaine, gives temporary relief;, after- 
effects bad, 228 
Cubebs, troches of, used in chronic types, 

250 
Monsel's solution, pure or diluted one-half 
with glycerin, applied on pledgets of 
cotton or camel-hair brush, 338 
Peroxide of hydrogen, 310 
Potassium chlorate, as a gargle, 453 
Salol (phenvl salicylate), in 5-gr. (0.3) doses, 

470 
Silver nitrate solution, in varying strength, 

locally applied, 389 
Turkish bath in acute .forms when phar- 
ynx feels raw, 588 

PHTHISIS. (See Tuberculosis.) 

PITYRIASIS VERSICOLOR. 

Anthrarobin in, 98 

Sodium thiosulphate, 1 drachm to the ounce 
(4.0-30.0) of water or lard useful, 486 

PLEURITIS OR PLEURISY, 878 

Aconite or veratrum, preferable to vene- 
section, in early stage, 878 

Aspiration, when hydragogue purges fail 
to remove effusion, 880 

Bryonia in pleurisy with effusion, 159 

Cantharidal blister, two inches below 
axilla, aids absorption of effusion, 575, 880 

Cotton jacket, 878 

Digitalis or alcohol, if pulse weakens in 
second stage, 878 

Elaterium or jalap, useful to remove effu- 
sion, 261 

Gelsemium, 291 

Iodide of potassium, used in chronic stage, 
to aid absorption, 318 



Iodine, locally applied, to abort, and aid 

absorption of fluid, 323 
Pilocarpine, 442 
Pulmonary exercises in deficient expansion 

because of adhesions following an attack, 

600 
Salicylates very useful for the removal of 

effusion, 466 
Saline purges, in -second stage, to remove 

effusion, 880 
Strapping chest, if respiratory movements 

are very painful, 878 



PLEURODYNIA. (See Neuralgia.) 

PNEUMONIA, 881 

Aconite, preferable to veratrum, in early 
stage, in children, 73 

Alcohol, inferior to digitalis, as a cardiac 
stimulant in the second stage in adults, 
but better than in children, 78, 883 

Ammonia useful for adults and children, 
90, 885 

Ammonium bromide and carbonate may 
be used if the chloride fails, 886 

Ammonium chloride, as an expectorant in 
•third stage, 886 

Antipneumococcic serum, 549 

Antipyrine of great value, if fever is exces- 
sive, 106 

Asafcetida, by rectal injections, in tym- 
panites, 133 

Belladonna, very useful, if there are evi- 
dences of collapse, 142, 884 

Citrate of potassium to maintain renal 
activity, 885 

Climatic treatment in convalescence, 619 

Cold compresses, locally, 883 

Cold sponging for fever, 883 

Counterirritation in, 575 

Digitalis, tincture, 1U 8 (0.5), every four 
hours, accompanied by belladonna, gtt. 
8 (0.5), carefully watched in second 
stage, 256, 883 

Dover's powder for pain at onset, 882 

Ethylhydrocuprein hydrochloride an effi- 
cient destroyer .of pneumococci, 279 

Ethyl iodide, causes resolution, 280 

Fresh air, 881 

Gelsemium, in early stages, 291 

Gin, to maintain renal activity, 83, 341, 885 

Heroin, gr. ^ (0.005) every eight hours, 
for excessive cough, 886 

Hot foot-bath, useful at onset, 882 

Ice-bag to heart if -fever be high and heart 
tumultuous, 559, 881 

Iodide of potassium, in later stages to ab- 
sorb exudates, 319 

Morphine, for pain at onset, and for exces- 
sive cough and persistent insomnia, 413, 
882, 885 

Oxygen inhalations if asphyxia threatens, 
419, 885 

Phosphorus, 437 

Phylacogens. 623 

Prescriptions, containing ammonium chlo- 
ride, to loosen cough of second stage, 886 

Pulmonary exercises in delayed resolution, 
600 

Quinine, gr. 2 (0.12) thrice daily, in sup- 
pository in lobar pneumonia of children, 
219 



INDEX OF DISEASES AND REMEDIES. 



1011 



Spirit of ether or aromatic spirit of ammo- 
nia, 1 dram of each every hour if collapse 
threatens, 885 

Strychnine as a respiratory and circulatory 
stimulant in second stage and as an 
adjuvant to digitalis, 403, 884 

Sweet spirit of nitre to maintain renal 
activity, 885 

Venesection, in early stage of sthenic cases, 
cardiac depressants preferable, and late 
when heart is laboring and veins dis- 
tended, 637, 882, 884 

POISONING FROM— 

Acetanilid. 

Supportive measures, stimulants, external 
heat, belladonna to maintain blood- 
pressure, strychnine to counteract res- 
piratory failure, and oxygen inhalation 
to overcome cyanosis, 66 

Acetate of Zinc. 

Treatment same as for Gastro-enteritis, 531 

Acetic Acid 

Large amounts of milk, alkaline liquids, 
and general treatment for gastro-enter- 
itis, 69 

Aconite. 

Keep patient in prone position, with feet 
higher than head. Hot applications; 
emetics contraindicated; evacuate stom- 
ach by siphon or stomach-pump. Ether 
hypodermically, followed by alcohol, and 
this by digitalis. Artificial respiration 
and amyl nitrite a few whiffs, no more, 
if heart fails; atropine, strychnine, 72 

Alcohol (Acute). 

External heat, digitalis and strychnine 
hypodermically, in coma, if heat fails. 
Belladonna, if the skin is relaxed and 
clammy, and counterirritation to nape 
of neck for brain symptoms. After- 
treatment, ammonia, spices, spirit of 
mindererus; emollients in gastritis, ice. 
aconite, hydrochloric acid, or ipecac in 
minute dose, and counterirritation for 
vomiting. Jalap, gr. 40 (2.6), elaterium, 
gr. | (0.01), or calomel and salines, as 
purgatives, 79 

Fowler's solution for morning vomiting, 79 

Alcohol (Chronic). 

Withdrawal of drug, at once or gradually. 
Highly seasoned broths, predigested 
food, and morphine or coca, in small 
dose, if weakness is marked. Capsicum, 
prescriptions (page 81), 80, 179 

Antimony. 

Large doses of tannic acid, external heat, 
alcohol, digitalis, and opium hypoder- 
mically, if respiration is not too feeble. 
If necessary to use opium, it should be 
accompanied by strychnine. Prone posi- 
tion, patient vomiting into towels. 
Stomach-pump, if vomiting is absent 
103; atropine, 140 



Antipyrine. 

Maintain bodily heat, stimulants, atropine, 
and oxygen inhalations, if cyanosis is 
alarming, 105 

Arsenic (Acute and Chronic). 

Stomach-pump, external heat, stimulants 
and the chemical antidote, hydrated 
sesquioxide of iron and magnesia. Mag- 
nesia also useful by itself. Opium should 
follow antidote, to allay pain, also large 
draughts of water to flush kidneys and 
dilute poison. For chronic poisoning, 
iodide of potassium, tonics, electricity, 
and out-of-door life, 122, 123 

Belladonna. 

External heat if collapse intervene, and 
strychnine to support respiration. The 
physiological antidote, opium, may be 
carefully given, 140 

Carbolic Acid (Phenol). 

Soluble sulphates, as Epsom or Glauber 
salts, warm mucilaginous drinks, hot 
applications to extremities, digitalis, 
strychnine, and counterirritation over 
abdomen. Emetics and stomach-pump 
should be used if possible, 430 

Chloral. 

External heat, emetics in early and stomach 
pump in later stages. Strychnine or atro- 
pine to stimulate respiration. Digitalis 
preceded by ether, ammonia, brandy, or 
whiskey. Prone position, feet being ele- 
vated, 188 

Chloroform. 

Artificial respiration, ether and hot brandy 
hypodermically. Poles of battery with 
rapidly interrupted current swept over 
body, not over diaphragm or phrenic 
nerve. Place patient with head down- 
ward. Compression of the abdomen 
and limbs; compression and massage of 
the prsecordium. Atropine, strychnine, 
and digitalis to stimulate the heart and 
respiration. Laborde's lingual traction, 
208 

Cocaine. 

Ammonia, coffee, strychnine, ether, and 
alcohol. If convulsive in type, treat 
same as Strychnine-poisoning, 232 

Colchicum. 

Tannic acid, emetics, and stomach-pump. 
Opium to relieve pain, and oils. Atro- 
pine and stimulants if collapse comes 
on, 237 

Conium. 

Emetics or stomach-pump, strychnine as 
a nervous and respiratory stimulant, 
external heat, and cardiac stimulants, 
if circulation fails, 241 

Copper. 

Yellow prussiate of potassium, sweet oil, 
white of egg; followed instantly by 
emetics or stomach-pump. If emesis or 
purgation is present, emetics are contra- 
indicated; instead, mustard plaster over 
abdomen, and opium internally, are often 
employed, 243 



1012 



INDEX OF DISEASES AND REMEDIES. 



Corrosive Sublimate. 

Large amounts of white of egg, followed 
by stomach-pump, external heat, stimu- 
lants, 368 

Croton Oil. 

Treatment same as for Gastro-enteritis, 250 

Digitalis. 

Tannic acid as a chemical antidote, emetics 
or stomach-pump, external heat to 
abdomen, and aconite as a physiological 
antidote. Maintain horizontal position, 
256 

Elaterium. 

Treatment same as for Gastro-enteritis, 262 

Ether. 

Artificial respiration, lowering head if face 
is pale; strychnine, atropine, and digi- 
talis hypodermically, or intravenous in- 
jection of ammonia to stimulate heart 
and respiration; friction and hot applica- 
tions; ether dashed on chest and abdo- 
men; Laborde's method of traction of 
the tongue, 269 

Eucaine. 

Treatment like that of Cocaine intoxica- 
tion, 281 

Formaldehyde. 

Ammonia water, chemical antidote; wash 
out stomach, soothing drinks, morphine 
for pain, 288 

Gelsemium. 

Emetics and stomach-pump, digitalis, atro- 
pine, and ammonia as cardiac stimulants ; 
external heat, strychnine, and atropine 
for respiratory centre, 291 

Iodine. 

Emetics or stomach-pump, large amounts 
of starch, hot applications, and hypo- 
dermic injections of alcohol, ammonia, 
atropine, digitalis, or strychnine, 321 

Iodoform. 

Sodium bicarbonate to combine with iodine, 
alcohol, diuretics, and hot blankets; 
saline transfusion, 326 

Lead (Acute). 
Epsom or Glauber salts, in large amounts; 
alum; emetics or stomach-pump. Hot 
applications and opium to relieve pain, 
345 

Lead (Chronic). 

Jalap and calomel with opium or alum, 
gr. 2 (0.12), in full dose, valuable in lead 
colic. Blister to back of neck, revulsives, 
and pilocarpine in cerebral inflamma- 
tion. Iodide of potassium to eliminate 
lead. Strychnine in progressive paraly- 
sis. Electricity and baths of sulphuret 
of potassium, 347 

Mineral Acids. 

Alkalies, such as magnesium, lime, white- 
wash, and soap as antidotes; white of 
egg, external heat, oils, and opium, to 
relieve irritation. 



Monsel's Solution. 



Soap, 338 



Nitrate of Silver (Acute). 

Common salt as the chemical antidote, 
opium and oils to allay irritation; also 
large amounts of milk and soap and 
water; maintain bodily heat, 387 

Nitrate of Silver (Chronic). 

Iodide of potassium, to aid in eliminating 
poison, 388 

Nux Vomica and Its Alkaloids. 

Inhalations of amyl nitrite, to prevent con- 
vulsive tendencies; at the same time use 
stomach-pump. Tannic acid followed 
by physiological antidotes, potassium, 
bromide, gr. 60 (2.0), with chloral, gr. 
20 (1.3). If convulsions prevent swal- 
lowing, chloroform patient carefully and 
give antidotes by rectum in starch- 
water. Amyl nitrite, hypodermically, if 
relaxation does not occur, 405 

Opium (Acute). 

Emetics, or stomach-pump, tannic acid, 
black coffee, electricity, and other meas- 
ures to keep patient awake. Atropine 
or strychnine, hypodermically, if respi- 
ration fails. Alcohol, ammonia, and ex- 
ternal heat. Artificial respiration may 
be necessary; repeated washing out of 
stomach. Permanganate of potassium, 
408 

Opium (Chronic). 

Decrease a sixth or fourth of customary 
amount each twenty-four hours. Co- 
caine not advisable as a substitute, as 
the cocaine-habit may be' established. 
Digitalis and strychnine if heart fails. 
Hyoscine hydrobromide in large doses 
very valuable, 410 

Phosphorus. 

Permanganate of potassium, 1 per cent, 
solution, or peroxide of hydrogen. Sul- 
phate of copper is too poisonous in itself, 
436 

Physostigma. 

Atropine as a physiological antidote, ex- 
ternal heat, and cardiac and respiratory 
stimulants, 438 

Scammony. 

Treatment same as for Gastro-enteritis, 474 

Strychnine. (See Nux Vomica.) 

POLIOMYELITIS. 

Uro tropin as a prophylactic, 301 

POST-PARTUM HEMORRHAGE, 817 

Adrenalin chloride, 817 

Auto-transfusion, or actual transfusion of 

weak salt solution, necessary in some 

cases, 895 
Beef -tea, \ pint (240.0), and morphine, gr. 

| (0.008), hypodermically, after reaction 

is established, 895 



INDEX OF DISEASES AND REMEDIES. 



1013 



Correction of displacement sometimes neces- 
sary, 895 
Drugs have been recommended, but are 

dangerous as local applications, 895 
Enema of hot normal salt solution. 1 pint 

(480.0), after cessation of bleeding, 895 
Ergot, as a cure and prophylactic, 264, 817 
Faradism of uterine muscle, 895 
Gauze, preferably iodoform, packed into 

uterine cavity, 895 
Ice, used externally and internally, 895 
Manipulations of the uterus, 895 
Method to pursue when caused by haema- 

toma, 895 
Pituitrin, 15 minims, hypodermically, 817 
Suture, if due to laceration, 895 



PRIAPISM. 



Hops, 304 



PROLAPSUS ANI AND RECTI. 

Quercus, infusion, 458 

PROSTATITIS, 792 

Local treatment to prostatic urethra, and 

use of cold steel sounds in chronic types, 

792 
Perineal incision, to evacuate pus, if 

abscess forms, 792 
Rest in bed, regulation of bowels, leeches 

to perineum, medication to render urine 

alkaline and morphine hypodermically, 

or in suppository, 792 
Soft catheter, allowed to remain in bladder, 

if retention of urine is persistent, 792 

PROSTATORRHCEA. 

Cantharides, 178 

PRURIGO. 

Cantharides, 178 

PRURITUS, 887 

Alum solution in pruritus vulvae, 87 
Arsenic, quinine, bitter tonics, cod-liver 

oil, alkaline diuretics or mineral waters, 

in debility, and avoidance of condiments 

if mouth of vagina or urethra is affected, 

118, 887 
Boric acid, 149 
Brewers' yeast, 1 tablespoonful to a quart 

of water, may be used on a compress in 

diabetic pruritus vulvae, 888 
Calomel and lard (1 drachm to the ounce 

[4.0 : 30.0]), locally applied, 374 
Chloride of calcium, prescription for, 165 
Chloroform may be used, 888 
Cocaine, relieves temporarily, 888 
Conium ointment in pruritus ani, 241 
Goulard's extract, dilute, useful in pruritus 

pudendi, 349 
Hydrastis, 2 ounces of fiuidextract, injected 

into rectum, may be advantageous, 888 
Hydrocyanic acid, locally applied, 309 
Ivory plug for, 888 

Lead-water useful in pruritus pudendi, 350 
Linseed-meal baths, or bran baths, when 

skin is irritated, 889 



Phenol, 887; prescriptions for, 432 
Prescriptions for lotions and ointment, 888 
Salicylic acid, prescription for, 466 
Silver nitrate (gr. 20 to the ounce [1.3 : 
30.0]), locally applied, preceded by 
cocaine, if itching is intense; a 4- to 6- 
grain (0.25-0.4) solution may relieve 
itching of pruritus pudendi, ani, and 
vulvae, 389, 888 
Sodium bicarbonate or borax (1 drachm to 

the pint [4.0-480.0]), as a wash, 888 
Sodium thiosulphate. gr. 30 to the ounce 

(2.0-30.0), locally, 486 
Turkish baths, 888 

PSEUDOLEUKEMIA. 

Arsenic internally, and injections of Fow- 
ler's solution into glands, 116 

PSORIASIS. 

Ammoniated mercury in, 368 

Anthrarobin, 98 

Aristol, 512 

Arsenic, 118 

Cantharides, 178 

Chrysarobin, gr. \ (0.008) internally, or the 
ointment with benzoated lard (1 to 4 
or 5), locally applied, face excepted: 
prescription for application, 213 

Gallic acid, ointment, 288 

Pyrogallol, 30 grains to ounce (2.0 : 30.0) 
of lard, 457 

Resorcinol, prescription for, 459 

Tar, locally applied, 506 

Thymol iodide, 512 

Thyroid gland, 513 

PTYALISM. 

Alum, applied on swab, in mercurial 

ptyalism, 87 
Belladonna in idiopathic or mercurial 

types, 141 

PUERPERAL DISEASE, 889 

(For treatment see special titles.) 

PUERPERAL FEVER, 889 

Antipyretics, best abstained from as long 
as possible, 890 

Antistreptococcic serum, nuclein, and in- 
jections of normal salt solution impor- 
tant adjuvants, 551, 890 

Argyrol. 25 per cent., or 5 per cent, emul- 
sion of silver iodide, a 1 per cent, solu- 
tion of hegonon or a 5 per cent, solution 
of silvol injection into bladder after 
irrigation, 892 

Bier's cups, 893 

Boric acid or oxy cyanide of mercury (1 : 
5000) solution, as injections into bladder, 
to prevent septic cystitis, 892 

Curette or placental forceps, to remove 
membranes if fever continues after anti- 
septic injections, 890 

Epsom salt, concentrated solution, 2 
drachms (8.0) every fifteen minutes, if 
peritonitis develops, 891 

Hot fomentations, or ice-bag, and later 
compresses dipped in lead-water and 
laudanum, 893 



1014 



INDEX OF DISEASES AND REMEDIES. 



Iodoform (5 grain) suppositories and boric 
acid irrigations in septic proctitis follow- 
ing, 892 

Laparotomy, occasionally saves life, if 
septic peritonitis develops, 891 

Lugol's solution, 2 drachms to the quart, 
as uterine douche, 889 

Nutriment in large amounts and alcoholic 
stimulants, if symptoms of systemic in- 
vasion arise, 890 

Salol and urotropin if renal infection ensues, 
892 

Silver nitrate (gr. 40 to 60 to the ounce 
[2.60-4.0 :30.0]), locally applied to un- 
healthy ulcerated wounds; zinc chloride 
solution may be necessary, 891 

Vaccines useful, 890 



PULMONARY (EDEMA. 

Adrenalin solution, 10 to 15 minims intra- 
muscularly, mav be used with advantage. 
501 

Atropine, in large dose, is the best remedy 
we have, 142 

PURPURA HEMORRHAGICA. 

Turpentine, 525 

PYELITIS. 

Buchu in chronic types, 160 

Cantharides, 178 

Copaiba, useful in subacute stage, 242 

Juniper, as a tonic in chronic types, 341 

Pareira, 423 

Urotropin, 301 

Uva ursi, 526 

QUINSY. 

Aconite, in early stage, 73 

Salicylic acid, gr. 3 (0.2) hourly, acts as 
a specific, especially if due to rheuma- 
tism, 466 



RELAPSING FEVER. 

Arsphenamine (salvarsan), a specific, 127 
Atoxyl valuable in, 135 

REMITTENT FEVER, 842 

Calomel will often relieve vomiting. 367 

Cool sponging with friction if fever is ex- 
cessive, 842 

Eupatorium, 283 

Morphine, spirit of chloroform, or aconite, 
in sthenic cases, to control vomiting, 842 

Quinine, gr. 20 to 30 (1.3-2.0), preceded 
by calomel, gr. 3 to 4 (0.2-0.25) ; if not 
retained, administer by rectum, or hypo- 
dermically, with divided doses of Seidlitz 
powder by mouth, 218, 842 

Tonics, potassium salts, to regulate kidneys 
and purgatives if necessary, during con- 
valescence, 842 

Turpentine stupe, if belly is tender, 842 

RETINITIS, 900 

Atropine, dark glasses, and later suitable 
lenses, if due to eye-strain, 900 



RHEUMATISM, ACUTE (ARTICU- 
LAR), 900 

Acetanilid relieves pain and fever, 67, 902 
Acetate of potassium, 450, 903 
Ammonium bromide and phosphate, 93 
Antimonial powder as an antipyretic, 102 
Antipyrine, gr. 5 to 10 (0.3-0.6), or anti- 

febrin, gr. 4 to 8 (0.25-0.5), often very 

valuable, 106 
Aspirin in acute cases, 135 
Benzoic acid, drachms 2 to 3 (8.0-12.0) 

daily, said to be specific, 145 
Bicarbonate or citrate of potassium, gr. 20 

to 30 (1.3-2.0), in water, every five hours, 

in obstinate cases, 903 
Bicarbonate of sodium, 465, 901, 902 
Blisters over joints, useful after systemic 

disturbance is past, 904 
Caffeine useful to support the heart, 903 
Camphor liniment, 172 
Capsicum plaster, 180 
Cimicifuga, shortens attack and relieves 

pain in some cases, 214, 903 
Colchicum, prescription for, 236, 903 
Fuller's lotion applied on hot cloths to 

joints, 901 
Guaiac, 296 
Hot baths useful, 617 
Ice-cold compress, may relieve inflamed 

joints, 901 
Ichthyol, ointment, valuable, applied to 

joints, prescription for, 314, 901, 904 
Iodine, ointment or tincture, painted over 

parts, 904 
Leeches, over prrecordium in endocarditis, 

during, 904 
Lemon-juice or lime-juice, or citric acid, 

beneficial in nearly all cases, 225, 904 
Magnesium, sulphate solution locally to 

relieve pain, 358 
Morphine in endocarditis, 904 
Novaspirin, 400 
Oil of gaultheria, useful as a substitute for 

salicylic acid; also used as a local applica- 
tion to the joints, 290 
Oleum succini, applied locally over joints. 

89 
Phenacetin, alone or with salol, 70, 903 
Phenocoll, 428 
Phylacogen specific in its effects in some 

cases, 622, 903 
Potassium iodide, useful in subacute or 

obstinate types, prescription, 318, 903 
Potassium nitrate, 455 
Salicin used in place of salicylic acid, 463 
Salicylic acid, gr. 20 (1.3) thrice daily; if 

untoward symptoms arise, it must be 

stopped, 465, 902; applied to joints in a 

salve when stomach is irritable, 467, 901 
Salol (phenyl salicylate), useful as a sub- 
stitute for salicylic acid; dangerous in 

large doses, 470 
Sodium bicarbonate (gr. 20 to the ounce 

[1.3 : 30.0]), to inflamed joints, 483, 901 
Splints for fixation of limbs, may relieve 

greatly, 901 
Strontium salicylate useful when other 

drugs are not well borne, 492, 902 
Vaccine therapy, 902 
Veratrine ointment, used locally, applied 

to joints, 528, 904 



INDEX OF DISEASES AND REMEDIES. 



1015 



RHEUMATISM (CHRONIC), 904 

Arsenic, useful in some cases, 118 

Cimicifuga, sometimes relieves, 214 

Citric acid, 225 

Cod-liver oil, internally; also useful rubbed 
into joints, 234, 905 

Colchicum. with iodide of potassium, pre- 
scription for 237. 905 

Hot-air bath, 595 

Icbthyol, the best remedy for joints, 906 

Iodine, locally applied, 322 

Liniments, prescription for, 905 

Ointments, prescription for, 906 

Potassium iodide, colchicum, and sarsa- 
parilla, usually indicated; see Prescrip- 
tions, 318, 905 

Salophen, 471 

Sulphur, 497 

Turkish or Russian baths very valuable, 
588, 905 

Veratrine ointment, gives greatest relief in 
eome cases, prescription for, 528, 905 

RHEUMATISM (GONORRHEAL). 

Antigonococcic serum in. 548 

RHEUMATISM (MUSCULAR). 

Acetanilid in subacute, 67 

Ammonium benzoate useful in certain 

cases, 92 
Bergundy pitch, a mild local remedy, 446 
Croton-oil ointment; 249 
Dover's powder in conjunction with hot 

drinks and hot foot-baths, often cures. 

414 
Mustard as a counterirritant, 383 
Novaspirin. 400 

Oil of cloves in liniment, locally 226 
Pitch, locally, 446 
Salicin useful as a substitute for salicylic 

acid, 463 
Salol useful, 470 
Veratrine ointment, locally applied, 528 

RHINITIS. 

Creolin (1 : 1000), as a nasal douche, 245 
Dobell's solution as a wash, 149 
Fluid petrolatum, in spray, 428 
Pituitrin, diluted from three to ten times 

with normal salt solution, used locally, 

448 
Potassium permanganate, solution, in 

foetid rhinitis, 427 

RHUS POISONING. 

Aluminum acetate useful, 88 

Ammonium chloride, 95 

Grindelia, 296 

Infusion of lobelia, 354 

Lead acetate, 348 

Liquor plumbi subacetatis, 349 

RICKETS, 906 

Arsenite of copper, 907 

Cinchona or strychnine, 907 

Cod-liver oil, prescription for, 234, 907 

Cool sponging or rubbing with salt and 

whiskey (1 drachm to the pint [4.0 : 

480.0]), useful at night, 908 



Hypophosphites and lactophosphates use- 
ful, 166 

Iodide of iron, syrup of, if scrofulous ten- 
dency or anaemia exists, prescription for, 
907 

Lecithin, as a tonic, 350 

Lime salts, phosphorus, zinc phosphide, as 
bone tonics. 907 

Massage and passive movements, 908 

Mineral acids, physostigma and simple 
bitters, as digestive tonics, 907 

Nux vomica, rarely given because of bitter- 
ness, 907 

Phosphorus, gr. T J^ (0.0006). in sugar- 
coated pill, 437, 907 

Quinine, cod-liver oil, nux vomica, and 
iron as general tonics, 907 

Sodium and lime salts, useful in nursing 
and pregnant women, 907 

Sodium phosphate to regulate the bowels, 
485 

RINGWORM (See Tinea Circinata.) 
SATYRIASIS. 

Potassium bromide, one of the best reme- 
dies, 153 

SCABIES. 
Sulphur, the best remedy, 497 

SCARLET FEVER, 908 

Aconite, harmful if constantly employed, 73 

Antidiphtheritic serum, when false mem- 
brane forms in throat, 910 

Antipyrine or acetanilid may produce col- 
lapse in large doses, 106 

Antistreptococcic serum, 551 

Benzoated lard, or almond oil, useful 
locally applied, to allay itching, 910 

Bromide of sodium, with chloral, useful 
when convulsion ushers in attack, 908 

Chlorate of potassium, locally applied by 
spray or swab, in sore throat, 910 

Cold sponging, useful, 909 

Diet, 909 

Dry cuds, 909 

Hot packs, 909, 910 

Hydrogen peroxide to throat if a mem- 
brane is present, 910 

Ice applied externally and held in mouth, 
to prevent swelling of throat, 909 

Ice-bag or rubber head-coil to head, if very 
hot, 909 

Juniper, in later stages, if there is renal 
atony, 341 

Potassium citrate and sweet spirit of nitre, 
prescription for, 909 

Potassium permanganate (gr. 20 to pint 1 
[1.3 : 480.0]), as a gargle, 427 

Rectal drip, 909 

Strychnine, iron, simple bitters, quinine, or 
Basham's mixture, in convalescence, 910 

Sweating, necessary in nephritis, 910 

Warm wet pack, useful to bring out rash, 
909, 910 

Water, pure, such as Vichy or Poland, in 
large amounts, 908 

SCIATICA, 911 

Absolute rest of limb in splints very need- 
ful, 911 



1016 



INDEX OF DISEASES AND REMEDIES. 



Acetanilide and antipyrine, 67, 911 
Acupuncture, recommended. 535 
Chloroform, deeply injected over exit of 

nerve, a favorable remedy. 208 
Cod-liver oil, of service in obstinate cases. 

234, 911 
Cold applications, 558 
Ether or rbigolene sprayed on part, often 

effective, 911 
Hot-water bags, placed around exit of 

sciatic nerve, 911 
Kataphoresis, 911 
Liniments for rheumatism, may be tried, 

911 
Methylene-blue, gr. 5, twice or thrice a 

day to relieve pain, 911 
Opium subcutaneouslv over affected part, 

412 
Potassium bitartrate or citrate, gr. 40 (2.6) 

thrice daily, in plenty of water, to regu- 
late kidneys, 911 
Potassium iodide, 318 

Remedies for rheumatism often relieve, 911 
Salicylic acid, 466 
Sulphur, 497 
Wet or dry cups, highly beneficial over 

course of nerve, 911 

SCLERITIS, 768 

Atropine, boric acid and hot-water com- 
presses, in early stages, 769 

Eserine. with pilocarpine sweats or cautery, 
in stubborn episcleritis without iritis, 769 

Specific treatment, in syphilitic cases. 769 

Yellow-oxide ointment, associated with 
massage to subdue infiltration. 769 

SCLEROSIS. 

Antipvrine, 107 
Nitrate of silver, 388 

SCROFULOSIS, 911 

Arsenic or corrosive sublimate, useful if 
anaemia is present, prescriptions for, 912 

Cod-liver oil, the best remedy, 234, 912 

Diet and exercise, 912 

Europhen in scrofuloderm. 284 

Excision, or scraping gland, and packing 
with iodoform gauze if other treatment 
fail, 913 

Hypophosphite of calcium, 167 

Ichthyol ointment, useful, rubbed into per- 
sistent enlargements, prescription for, 912 

Iodine ointment and lard, equal parts, 
rubbed into glands, stopping at first 
sign of reddening or fluctuation, 321, 912 

Iron, syrup of the iodide, in anaemia, pre- 
scription for, 336, 912 

Lactophosphates, or hypophosphites, with 
cod-liver oil, useful in young children, 912 

Phosphate of sodium or lime, if glands are 
breaking down, 167 

Sulphurate of calcium, if suppuration is 
active, 912 

SCURVY, 913 

Arsenic and iron, of service in most cases, 

913 
Citric acid, if lemon-juice is not attainable, 

225, 913 



Diet, 913 

Lemon-juice or lime-juice, particularly indi- 
cated, 913 
Sodium citrate tends to prevent, 484 

SEA-SICKNESS. 

Bromides, the best prophylactics, 154 
Chloral-formamide and potassium bromide. 

191 
Chloretone valuable, 192 
Nitrite of amyl, 98 
Kola, 342 



SEBORRHEA CAPITIS. 

Resorcinol valuable; prescription for, 459 

SHOCK, 913 

Adrenalin chloride solution 1 : ^000, ? 
drachm in 1 pint of hot normal saline 
solution injected into a vein, 501, 914 

Alcohol, 78 

Atropine in full dose, intramuscularly, with 
hot applications, very useful in first or 
second stage, 142, 914 

Caffeine valuable, 914 

Digitalis, valuable as an adjuvant to atro- 
pine, 256, 914 

Heat, external, very useful. 914 

Hypodermoclysis. useful, 596. 914 

Intravenous saline injections, 609, also 
salines by Murphy drip, 914 

Pituitrin useful in surgical shock, 448 

Strychnine, very valuable. 403, 914 

SINUSES. 

Bismuth subcarbonate with petrolatum, 
33 per cent., by injection, in tubercular 
and other sinuses. 148 

Chalk as substitute for bismuth. 165 

SKIN DISEASES. 

Arsenate of iron. 333 

Arsenic, in dry, scaly types, 118 

Bismuth subgallate, when there is much 

secretion, 146 
Chrysarobin locally in parasitic disease, 213 
Cod-liver oil, in strumous types, 234 
Copper sulphate, gr. ^ (0.006) thrice 

daily, if arsenic is not well borne, 244 
Corrosive sublimate, oz. \ (1.6), and am- 
monium chloride, oz. 1 (30.0), useful 
added to bath, in syphiloderm, 371 
Hot mineral springs, in chronic skin dis- 
eases, 617 
Hydrocyanic acid, in itching types, pre- 
scription for, 309 
Ichthyol in those forms associated with 
atony and induration of the deeper 
layers, 315 
Ointment of biniodide and of yellow oxide 
and lard, in equal parts, useful applica- 
tion, 371, 377 
Opium allays nervous irritation caused by 

itching skin diseases, 413 
Petrolatum, as an emolient dressing, 428 
Pyrogallol in parasitic skin diseases, 457 
Sodium thiosulphate in pityriasis versi- 
color, 486 



INDEX OF DfSEASES AND REMEDIES. 



1017 



Tar ointment, and prescriptions containing: 

it, locally applied except on face, 506 
Unguentum hydrargyri ammoniati, 368 
Zinc oxide ointment, 532 

SMALLPOX, 914 

Aconite, with spirit of nitre and mindererus, 
useful as a fever mixture, 915 

Antipyrine or acetanilide to control head- 
ache and backache, 106, 915 

Brandy and whiskey, if pulse fails, 915 

Bromides and chloral, in insomnia; latter 
must be used carefully, 915 

Chlorate of potassium with tincture of 
myrrh, as a mouth-wash, 915 

Disinfection and hygiene necessary, 915 

Flexible collodion, glycerite of starch, or 
simple cerate, locally applied, to prevent 
itching, 915 

Iron, tincture of the chloride, to give 
strength, and act as a specific, 915 

Mustard plasters contraindicated, 915 

Opium for restlessness caused by itching, 
413 

Phenol and sweet oil (1 : 100), as an oint- 
ment to check irritation, 915 

Phenol, pure, touched to the vesicles to 
decrease pustulation, secondary fever, 
and pitting, 432 

Salicylic acid and vaseline, or cold cream 
(4 : 100), best local application, 915 

Silver nitrate, locally applied, to prevent 
pitting, 389, 915 

SORDES. 

Glycerin and water, equal parts, useful as 
a mouth-wash, 294 

SORES. 

Acetic acid, in old sores, 68 

Black wash, useful for syphilitic sores, 372 

Camphor, locally applied as a stimulant in 
indolent sores, 172 

Charcoal, applied to old sores as a deodo- 
rant and antiseptic, 181 

Cold cream, as an emollient dressing, 462 

Dried alum a useful dressing, 87 

Formaldehyde solution useful for cauter- 
izing syphilitic sores, 287 

Gallic acid, 288 

Iodoform, gr. 20 (1.3), with oil of eucalyp- 
tus, oz. | (16.0), or iodoform, oz. \ (16.0), 
camphor, gr. 75 (5.0), and essence of 
roses, gtt. 2 (0.1), as a dressing for syph- 
ilitic sores, 326 

Lactic acid bacilli used locally on septic 
wounds or in sinuses, 344 

Nosophen as a substitute for iodoform, 400 

Petrolatum, as an emollient dressing, 428 

Phenolsulphonates of sodium and zinc as 
mild antiseptic stimulants, 433 

Potassium permanganate (gr. 60 to the 
pint [4.0 : 480.0]), as a wash, 427 

Quercus, powdered as a poultice, to check 
discharge, 458 

Red or yellow oxide of mercury a good 
dressing for syphilitic sores, 377 

Salicylic acid as a salve or dusting-powder 
in venereal sores, 468 

Sulphuric acid, sometimes used as an 
escharotic in venereal sores, 498 

Zinc oxide ointment, 532 



SORE THROAT. 

Aconite, in early stage, 73 

Alum (gr. 20 to the ounce [1.3 : 30.0]), 

locally applied on swab, 87 
Arsenic, 118 
Belladonna of greatest service in some 

cases, 143 
Capsicum, tincture of, and glycerin, 180 
Copper sulphate (gr. 4 to the ounce [0.25 : 

30.0]), often of service in relaxed sore 

throat, 244 
Ethylhydrocuprein hydrochloride, \ grain 

(0.03) to the pint of a 1 to 1500 solution 

of thymol, is efficient as a gargle in pneu- 

mococcus sore throat, 280 
Gambir, as a gargle or in troches, 289 
Guaiac, 296 

Hamamelis in relaxed sore throat, 299 
Hydrogen peroxide (2 per cent, strength), 

in spray, in foetid types, 311 
Iodine in gargle in relaxed sore throat, 324 
Kino, as a gargle, 342 
Lysol in 1 per cent, solution as a gargle in 

septic sore throat, 355 
Myrrh, tincture of, diluted one-half, as a 

gargle, in ulcerated types, 384 
Phenol (1 : 100), in spray, in ulcerated 

types, 431 
Potassium chlorate gargle in anginose 

form, prescription for, 452 
Quercus, useful as a gargle, 458 
Rhus glabra, with glycerin and water, use- 
ful as a gargle, 461 
Salol useful in chronic sore throat due to 

lithaemic diathesis, 470 
Troches of morphine and ipecac, 331 



SPASMS. 

Belladonna, useful in urethral, anal and 

vesical spasm, 141 
Bromides in spasmodic contractions, 153 
Cannabis indica, useful in vesical spasm, 

176 
Conium, useful, if due to irritation of 

nerve-trunk, 241 
Ether, inhalation, relieves local spasms, 259 
Gelsemium in localized muscular spasms, 

291 
Hot pack, to relax, 592 
Hyoscyamus in local spasm or when pain 

is due to spasm, 311 
Nitrite of amyl, of service to relax, 97 



SPERMATORRHOEA. (See Emissions.) 

SPRAINS. 

Arnica, 113 

Camphor liniment, 172 

Cold applications, useful in sprained ankle, 

557 
Croton oil liniment, 249 
Hot-air bath, 586 

Hot bath, very useful in sprained ankle, 586 
Ichthyol ointment, well rubbed in, very 

useful, 315 
Lead-water and laudanum, 349, 414 
Leeches for relief of swelling, 614 
Soap liniment, 481 
Soap plaster, used as a support to sprained 

joints, 481 



1018 



INDEX OF DISEASES AND REMEDIES. 



Soluble glass, 480 
Turpentine liniment, 525 
Warming plaster, 446 

STINGS AND BITES, 915 

Alcohol in snake-bite, 78 

Ammonia or alkaline liquids, locally ap- 
plied to neutralize poison, 90, 915 

Antivenine, 916 

Corrosive sublimate, with flexible collodion 
(1 : 1000), painted over part; salicylic 
acid a useful addition, 915 

Hydrogen peroxide applied locally to 
hornet's sting, of great value, 311 

Ipecac paste for stings of bees, 331 

Ligature, or cleansing of wound, at once, 
to prevent absorption in snake-bite, 916 

Phenol (1 : 50 or 100), sponged over part, 
useful in mosquito-bites, 915 

Potassium permanganate, applied and in- 
jected around snake-bite, followed by 
alcohol in full dose, 427, 916 

Vinegar, dilute or pure, locally applied, 
often relieves insect-bites 916 



STOMATITIS, 916 

Borax, as a mouth-wash, prescription for, 

149, 916 
Bromide of potassium or sodium, gr. 1 to 10 

(0.06-0.6) thrice daily, when nervous 

irritability is excessive, 917 
Cleansing nipples, in breast-fed babies, 917 
Cocaine, before cauterization, 228 
Mel boracis, 150, 304 
Nitrate of silver, stick touched to sore spots 

when they fail to yield to other treat- 
ment, 389, 917 
Nitric acid, Tfl. 3 (0.2), in water, taken 

through tube, 391 
Nitro-muriatic acid, indicated when hepatic 

torpor exists, 917 
Peroxide of hydrogen, 917 
Phenol as a mouth-wash, 431 
Potassium chlorate, prescription for, 452, 

916 
Prescription for stomatitis associated with 

pyorrhoea alveolaris, 917 
Salicylic acid (1 : 250), as a mouth- wash, 

after blisters have broken, to allay pain, 

466 
Salines or rhubarb, if constipation exist, 916 
Sozoiodol (5 per cent, solution), locally 

applied, 487 
Sweet spirit of nitre, 1U 10 (0.6), well 

diluted, to a one- or two-year-old child, 

and a warm foot-bath, before retiring, 

to produce rest, 917 
Thymol, prescription for, 511 
Tonics and careful diet after the attack, 917 



STYES, 917 

Boric acid (saturated solution), collodion 
(ethereal solution), or red or yellow 
oxide of mercury salve (gr. 2 to the 
ounce [0.12 : 30.0]), locally applied to 
abort, 917 

Calx sulphurata. if they tend to return, 918 

Collodion, 917 

Hot compresses, to alleviate pain, 917 

Incision, as soon as pus forms, 917 



Tonics, if general health is poor, 917 

Vaccines, 918 

Yellow mercuric oxide ointment, 377, 917 

SUBINVOLUTION OF UTERUS. 

(See Involution. Anomalies of.) 

SUNBURN. 

Almonds, in emulsion, 84 

Carbonate of lead, prescription for, 349 

SUNSTROKE, 918 

Antipyretics, almost useless, 106, 918 

Hot baths (105° to 110° F.), or hot bottles 
or bricks, in heat exhaustion, 919 

Ice, application to chest, back and abdo- 
men, as quickly as possible, in thermic- 
fever, 918 

Intravenous injections of normal salines, 
918 

Salicylic acid, quinine, and similar drugs 
contraindicated, 919 

Tonics, during convalescence in heat ex- 
haustion, 919 

Venesection, best treatment if face be 
cyanotic and heart laboring, and if men- 
ingitis threatens after thermic fever 
637, 918 

Veratrum may be used if meningitis threat- 
ens, 919 



SUPPRESSION OF URINE. 

Sparteine useful, 476 

SYNCOPE. 

Ammonia, if due to shock or indigestion, 90 

SYNOVITIS. 

Counterirritation, 575 
Iodine, 322 

Phenol (2 per cent, strength), as an injec- 
tion in chronic types, 432 

SYPHILIS, 919 

Arsphenamine in all stages, 126 

Atoxyl, the "third specific" in, 135 

Bichloride of mercury, hypodermically, 
364, 365, 369, 921, 922 

Biniodide of mercury, 371 

Calomel, hypodermically, 372, 374 

Calomel ointment, 4 drachms (15.0) to the 
ounce (30.0), used on penis, as a pro- 
phylactic against syphilis, 374 

Cod-liver oil, useful in advanced cases, 234, 
923 

Europhen, gr. 1 to 3 (0.06-0.2), internally, 
285 

Formaldehyde solution, useful for cauter- 
izing sores, 287 

Guaiac, not used at present, 296 

Hot baths useful, 617, 920 

Hypodermic injection of mercury, 364, 365, 
369, 372, 374, 375 

Iodides, followed if necessary by mercury, 
recommended by some, 317, 919 

Iodoform, gr. 1 to 5 (0.05-0.3), internally 
in tertiary stage, and the ointment ap- 
plied to ulcers, very useful, 326 






INDEX OF DISEASES AND- REMEDIES. 



1019 



Iodol, in tertiary stage, 328 

Mercurial ointment, by inunction, 376, 920 

Mercury by fumigation, general and local, 

362, 363, 921 
Mercury with chalk, chiefly employed in 

infantile syphilis, 375 
Neoarsphenamine (neosalvarsan). 386, 920 
Ointments and washes of mercury, and hot 

applications, 362, 922 
Prescriptions for blue mass and iron, 922 
Protoiodide of mercury, 377 
Salicylate of mercury, hypodermically, 365, 

922 
Salvarsan, in all stages, 126, 362, 910 
Sarsaparilla, a useful adjunct to potassium 

iodide, 474 
Sodium cacodylate, gr. 1 to 4 (0.06-0.25), 

by intramuscular injection every third or 

fourth day, 483 
Stillingia, used as an aid to other drugs, 

490 
Tonic and general treatment, 923 
Vapor baths, hypodermic injections, or 

inunctions, useful modes of applying 

mercury if it cannot be taken by mouth, 

618, 922 

SYSTEMATIC STRAIN. 

Opium, useful in prolonged physical strain, 

415 
Quinine, gr. 2 to 4 (0.12-0.25), useful to 

prevent exhaustion following physical 

and mental strain, 220 

TABES DORSALIS. (See Locomotor 
Ataxia.) 

Chloral formamide, prescription for, 191 
TAPE-WORM. (See Worms.) 

TEETHING. 

Bromide of potassium, to prevent convul- 
sions, 153 

TETANUS, 923. (See Poisoning 
from Strychnine.) 

Amyl nitrite, to relieve and prevent, 97 
Antitoxin, value of, depends upon how early 

it is given, 550, 923 
Chloral and bromide of potassium, by 

mouth or rectum, 189 
Chloretone an efficient palliative, 192 
Hot pack may be used, 592 
Iodine solution, 3 per cent., swabbed on 

point of infection, 923 
Magnesium sulphate solution, injected in- 

traspinally, materially aids in controlling 

spasms, 358 
Physostigma, of moderate value, 438 

TETANY. 

Calcium salts recommended in tetany due 
to disease or injury of parathyroid glands 
and for tetany of lactation and preg- 
nancy. 166 

Parathyroid gland, 423 

TICK FEVER (AFRICAN). 

Atoxyl valuable in, 135 



TINEA CAPITIS. 

Lime-water, locally applied, 169 

TINEA CIRCINATA, 908 

Borax, strong solution, locally applied, 149 
Iodine, applied with camel-hair brush, 323, 

908 
Turpentine, useful, applied, with a brush, 

526 

TINEA TARSI. 

Copper, crystals, or weak solution, applied 
to diseased eyelid, 244 

TINEA TONSURANS. 

Anthrarobin as a wash, 98 
Borax, strong solution, locally applied, 149 
Iodine, applied with camel-hair brush, 323 
Oil of cajuput, applied pure, 164 

TOE-NAILS (IN-GROWING). 

Absorbent cotton, soaked in strong alum 

solution, and inserted under nail, 87 
Liquor potassii hydroxidi, to soften nail 

prior to packing with cotton or partial 

evulsion, 353 
Phenol to produce local anaesthesia in 

eversion, 432 

TONSILLITIS, 924 

Alum stick, deeply applied, 87 
Ammonium iodide, for enlarged tonsils, 95 
Aspirin, locally in, 135, 924 
Bichloride of mercury, gr. ^ (0.0C03) 

every hour, in water, for four or five 

hours, to abort, 370 
Biniodide of mercury to abort, 371, 924 
Corrosive sublimate, when inflammation is 

severe, 370 
Glycerin and tincture of capsicum, equal 

parts, applied by swab, 180 
Guaiac, 296 

Guaiacol, applied locally, 297, 924 
Hot fomentations and gargles useful in 

some cases, 924 
Hydrogen peroxide (2 per cent, strength), 

in spray, in ulcerative types, 310, 924 
Ice-bag to throat, 924 
Iron, tincture of the chloride, 335, 924 
Monsel's solution, pure, applied with 

camel-hair brush, 338 
Novaspirin, 400 
Phenol, undiluted, useful in early stages, 

432, solution (1 : 100), as an antiseptic 

gargle, 924 
Salicylates are valuable in rheumatic 

cases, 466 
Saline purgative, followed by fever mixture 

of aconite, sweet spirit of nitre, and 

potassium citrate, 924 

TOOTHACHE. 

Chloretone dissolved in oil of cloves, ap- 
plied on cotton, 193 

Creosote, applied on cotton, often relieves, 
248 

Oil of cloves, inserted into cavity on. cot- 
ton, 226 

Oil of peppermint, applied on cotton, 424 



1020 



INDEX OF DISEASES AND REMEDIES. 



TORPOR. 

Acetate of potassium in hepatic torpor, 450 
Ammonium chloride, in hepatic torpor, 95 
Arsenic, in gastric torpor, 119 
Citric acid, in hepatic torpor, 225 
Euonymus, in mild hepatic torpor, 283 
Lactophosphates and hypophosphites, use- 
ful in hepatic torpor, 167 
Nitro-hydro chloric acid, in torpor of liver, 

395 
Pituitrin in postoperative intestinal torpor, 

448 
Russian and Turkish baths, useful in tor- 
pidity of skin and kidneys, 581 
Taraxacum, in hepatic torpor, 507 



TORTICOLLIS. 

Belladonna, injected into muscles, 141 
Gelsemium, 291 
Hot compresses, 587 



TREMOR. 



Hyoscine, 313 
Sparteine, 476 



TRYPANOSOMIASIS. 

Atoxyl useful in, 135 

Arsphenamine (salvarsan) is a specific, 127 

TUBERCULOSIS, 925 

Acetanilid, generally acts unfavorably, 66 

Agaracin, of doubtful value in night-sweats, 
75 

Almonds, essential oil of, recommended in 
cough, 84 

Alum (gr. 10 to 20 to the ounce [0.6-1.3 : 
30.0]), or sulphuric acid (1 drachm to 
the pint [4.0 : 480.0]), useful, sponge over 
body in night-sweats, 928 

Antipyrine, harmful, 106 

Arsenic, in phthisis, and in phthisical ten- 
dencies, 116, 119 

Artificial pneumothorax, 928 

Atropine, gr. T fo to T fo (0.0004-0.0006), 
hypodermically, in excessive night- 
sweats, 928 

Blister, small, useful over new pleuritic 
spots, 928 

Cacodylate of iron in albuminuria of, 334 

Camphoric acid, gr. 20 to 30 (1.3-2.0), in- 
valuable, 174, 928 

Cannabis indica, 175, 927 

Chloroform, spirit of, used by inhaler, often 
relieves cough, 927 

Cinnamic acid hypodermically and intra- 
muscularly, 224 

Climatic treatment, 619 

Codeine, recommended in excessive cough, 
233 

Cod-liver oil, rules for its use, 234, 926 

Copper in tubercular tendencies, 244 

Creosotal as an expectorant, 248 

Creosote, internally, in spray or by inhaler; 
often relieves cough and discomfort; 
contraindicated if fever and haemoptysis 
are present; prescription for, 246, 247, 
927 

Glycerin and water, equal parts, with 
lemon-juice, useful as a mouth-wash, 295 



Guaiacol carbonate more readily borne by 
the stomach than guaiacol, 298 

Guaiacol useful in, 297 

Heroin useful to stop cough, 928 

Hygienic measures, 925 

Inhalations of steam from corrosive subli- 
mate solution (1 : 10,000), stopping at 
first sight of mercurial effects, in laryn- 
geal phthisis; precede inhalation with 
cocaine spray (4 per cent, solution), 928 

Iodine useful, painted over new pleuritic 
spots, also useful in chronic cases as an 
inhalant, 321, 323, 928 

Iodoform emulsion (10 per cent.) useful 
in tubercular abscess, 327 

Iodoform with small amount of powdered 
talc and a little morphine, useful when 
puffed into the larynx in laryngeal tuber- 
culosis, 928; also used in spray, 327 

Iodol, of use in tubercular laryngitis, 328 

Lactic acid applications (10 to 60 per cent, 
solution), in laryngeal tuberculosis, using 
cocaine spray first to relieve pain, 928 

Lactophosphates and hypophosphites, 167 

Lecithin, used when nervous system is 
feeble, 350 

Levulose, as a substitute for sugar in die- 
tetic treatment, 351 

Morphine and wild-cherry bark in cough, 
prescription for, 927 

Oil of cloves, 226 

Opium, may be given in last stage to re- 
lieve pain and discomfort, 415 

Oxygen inhalations in dyspnoea, 419 

Phenol (Tfl. 5 to 15 to the ounce [0.3-1.0 : 
30.0]), in spray, 431 

Potassium cyanide, in excessive cough, 
prescription for, 454 

Silver nitrate (gr. \ to 2 to the ounce [0.03- 
0.12 : 30.0J), in spray, may be tried in 
laryngeal types, 389 

Sodium cacodylate, in ansemia, 483 

Strychnine, in dyspnoea, 403 

Sulphuric acid, internally, may relieve 
night-sweats, 499, 928 

Terebene, iodide of ethyl, and chloroform, 
equal parts, for inhalation, 927 

rhiocol as a substitute for creosote, 509 

Thoracic exercises beneficial in early stages, 
597 

Tuberculin, 518, 522 

TYPHOID FEVER, 931. (See Fever.) 

Acetanilid, generally acts unfavorably, 66 

Alcohol, useful throughout course of dis- 
ease, 78, 932 

Asafcetida, by rectal injections, in tym- 
panites, 133 

Belladonna, in cases of collapse or vaso- 
motor relaxation, 142 

Calomel, gr. \ (0.001) every fifteen min- 
utes, till gr. 1 (0.06) is taken, followed 
by magnesium sulphate, \ ounce (16.0), 
if constipation lasts two days, 373, 933, 
934 

Cascara sagrada, for constipation, 934 

Cold bathing, 563, 567, 933 

Diet, 932, 933 

Enemas, to be tried first, if constipation 
lasts over two days, 934 

Glycerin and water, equal parts, with a 
little lemon-juice, as a mouth- wash, if 
sores are present, 294, 934 



INDEX OF DISEASES AND REMEDIES. 



1021 



Guaiacol, an antipyretic in, 298 

Guaiacol carbonate, an intestinal anti- 
septic of value, 299, 935 

Hydrochloric acid, dilute, TTl 5 (0.3) every 
few hours, or, if bowels are inactive, 
nitrohydrochloric acid, 1U 3 (0.2), 307 

Hvpodermoclysis, if toxaemia is marked, 
935 

Ice-bag over the heart to relieve palpita- 
tion, 559 

Ice rub, 933 

Liquorice powder, drachm 1 (4.0), if con- 
stipation lasts over two days, 934 

Milk diet, 932, 933 

Morphine, only enough to relieve agony, if 
perforation occurs, 936 

Opium, for insomnia, 413 

Phenolsulphonate of zinc, useful, 433 

Phosphorus, if nervous system is affected, 
437 

Prescription for diarrhoea, 934 

Quinine inferior to new antipyretics, 219 

Reduction of fever by cold, 563 

Rest and diet, 932, 933 

Silver nitrate, gr. § to | (0.001-0.015), 
highly recommended, 388 

Sodium citrate, in indigestion of milk in 
typhoid fever, 484 

Sponging with tepid water and alcohol, 

_ with friction, of value when toxaemia is 
marked, 935 

Thymol, as an intestinal antiseptic, 511 

Turpentine, in the form of stupes, enemata, 
or by mouth, in tympanites, also useful 
in later stage, to relieve diarrhoea, heal 
ulcers, and prevent relapse, 524, 935 

Urotropin. (hexamethylenamine) to render 
the urine sterile and prevent cholecysti- 
tis, 301, 935. (For remedies for complica- 
tions — intestinal hemorrhage, pneumonia 
and pleurisy — see their titles.) 

Vaccines as prophylactic, 635 



ULCERS. 



Aristol, 512 

Burnt alum, as a dressing for old ulcers, 88 

Castor oil, with a few drops of balsam of 
Peru or oil of eucalyptus, excellent, 184 

Caustic potash, as an escharotic for exu- 
berant ulcers, 454 

Chloretone, with equal parts of boric acid, 
as an antiseptic dressing, 193 

Conium, used locally to relieve pain, 241 

Copper, in solid or powder form, locally 
applied to indolent ulcers, 244 

Creolin, solution (1 : 100), as a douche for 
nasal ulcers., 245 

Dionin as substitute for morphine in ulcer 
of stomach or bowel, 260 

Dried alum, useful, 87 

Europhen, in 10 per cent, ointment, in leg 
ulcers, 284 

Gallic acid ointment, in actively discharg- 
ing ulcers, 288 

Glutol, as an antiseptic powder, 288 

Hamamelis, locally applied on a cloth, 
relieve leg ulcers, 299 

Hydrogen peroxide, a useful application 
310 

Lime, as an escharotic in old ulcers, 168 

Methyl-blue in corneal ulcers, 380 



Nitric acid, as a caustic for phagedenic 

ulcers, or a solution (1TI 5 to 30 to the 

ounce [0.3-3.0 : 30.0]), locally applied to 

indolent types, 391 
Ointment of lead carbonate, as a dressing, 

349 
Potassium permanganate (gr. 60 to the 

pint [4.0 : 480. 0J), as an antiseptic wash, 

427 
Precipitated carbonate of calcium, as a dry 

dressing, 164 
Scarlet red in leg ulcers and syphilitic ulcers 

in from 2 to 8 per cent, ointment, 475 
Silver nitrate, by injection, for rectal and 

caecal ulcers, 388 
Sulphuric acid, sometimes used as an 

escharotic in slow ulcers, 498 
Tannic acid, useful locally, in indolent 

ulcers, 505 
Tincture of iodine, useful in leg ulcers, 323 
Unna's dressing, 532 

UNCINARIASIS. 

Aspidium, a valuable remedy in, 134 

Beta-naphthol valuable in, 145 

Oil of chenopodium often even better than 

thymol, 186 
Thymol is best remedy, 511 

UREMIA, 936 

Amyl nitrite to combat convulsions, 937 

Atropine, useful in pulmonary oedema,. 937 

Bromides for convulsions, 937 

Chloral and chloroform for convulsions, 
190, 937 

Dry cups over bases of both lungs in threat- 
ened pulmonary edema, 937 

Elaterium or elaterin, to aid elimination of 
poison by the bowel, 262, 936 

Ether, given bv the mouth or hypodermic- 
ally, 275, 937 

Heroin, for dvspncea, 300 

Hot pack, 936 

Hvpodermoclysis, 596, 937 

Nitroglycerin, to increase the urinary flow 
when arterial tension is high, 937 

Pilocarpine, gr. § (0.008), with strychnine 
gr. ^j (0.0012), to increase action of the 
skin, 442, 937 

Strychnine, followed by digitalis, for heart 
failure, 937 

Transfusion of salt solution of great value, 
609, 937 

Venesection, very useful, 609, 937 

URIC-ACID DIATHESIS. 

Acetate of potassium, 450 
Lime-water, 168 
Mineral waters, 616 

Piperazine in the dose of 15 grains (1.0) a 
day in 1 pint (480.0) of water, 444 

URTICARIA. 

Calcium chloride, to prevent, 166 
Magnesium carbonate often of value, 356 

UTERINE INERTIA. 

Kola useful, 342 

Pituitary gland in slow labor due to feeble- 
ness, 448 
Quinine not of great value, 219 



1022 



INDEX OF DISEASES AND REMEDIES. 



UVULA (RELAXED). 

Capsicum, tincture of, and glycerin, equal 

parts, as a gargle, 180 
Kino, as a gargle, 342 

VAGINITIS. 

Quercus, used as an astringent injection, 

458 
Zinc sozoiodol, 2 per cent, solution of value. 

487 

VITREOUS DISEASE, 938 

Antisyphilitic treatment, if due to svphilis, 
938 

Galvanism 938 

Leeches in early stage, if due to inflamma- 
tion, 938 

Pilocarpine, bypodermieallv, in opacities. 
442, 938 

VOMITING, 938 

Acetanilid, very useful, 67, 939 
Allium-juice, 1U 2 to 5 (0.12-0.3), useful in 

nervous vomiting, 83 
Arsenic, in vomiting of pregnancy, and of 

hand fed babies and of drunkards, 119 

941 
Bismuth and aconite may be of service, 

prescription for, 148, 940 
Brandy poured on cracked ice. very useful, 

79, 939 
Bromide of potassium, effervescing, 155 
Bromide of sodium, with laudanum, as a 

rectal injection, 939 
Calomel, 374 
Cerium oxalate often used instead of, or 

combined with bismuth, 186 
Chloretone, if due to irritation, and after 

etherization, 192, 939 
Chloroform, HI 1 to 2 (0.06-0.12). in water, 

940 
Cloves, oil of, sometimes controls, 226 
Cocaine or aconite, if due to hvperexcita- 

bility of stomach, 231, 939 
Corpus luteurn has given good results in 

vomiting of early pregnancy, 244 
Enemas, partially digested, if vomiting is 

incoercible, 941 
Faradism sometimes gives relief, 941 
Fowler's solution, gtt. \ to 1 (0.03-0.06) 

every two hours useful in nausea follow- 
ing debauch 79, 941 
Hydrochloric acid m 5 to 15 (0.3-1.0), in 

water, every two hours, in alcoholic 

nausea, 307, 941 
Hydrocyanic, acid dilute, HI 2 to 5 (0.1- 

0.3), in water, 308, 940 
Ice-bag to nape of neck, lumbar region, or 

epigastrium, 941 
Iodine and phenol, Tfl. 1 (C.06) of each in dr. 

2 (8.0) of water, 940 
Ipecac, in small doses, if due to gastric 

depression, vomiting of pregnancy, or in 

morning vomiting of drunkards, 329, 330, 

940 
Levulose, by rectum, in cylic or toxemic 

vomiting in children, 941 
Lime-water, added to milk, may relieve 

nausea, 168, 941 
Mustard plaster over stomach, useful in all 

cases, 941 
Nitroglycerin, very useful in some cases, 

393, 940 



Nux vomica, if due to gastric depression. 

prescription for, 940 
Opium when excessive, 414 
Peptonized milk, best food. 941 
Phenol or creosote, with bismuth, useful 

in acidity and fermentation, prescription 

for, 431, 940 
Podophyllin, useful in gastric depression 

and hepatic torpor, 449 
Seidlitz powder, often settles stomach, if 

due to constipation. 478 
Sodium bicarbonate by Murphy drip to 

prevent acidosis, 941 
Sodium bicarbonate in vomiting of acidosis. 

941 
Vinegar fumes of service when inhaled, 70, 

939 

VOMITING OF PREGNANCY. 

Aconite as a nervous sedative, 73 

Arsenic may be tried, .119 

Bromide of potassium as an effervescing 
draught, or with opium, by enema, pre- 
scriptions for, .155 

Cerium oxalate, gr. 2 to 5 (0.12-0.3), in 
pill, every four or five hours, 186 

Cocaine, useful to decrease irritability. 231 

Corpus luteum ; early, has given ' good 
results, 244 

Iodine, tincture of. largely used of late with 
good results. 325 

Ipecac wine, TTL 1 (0.06), or powder, gr. 2 
(0.12). useful in some cases, 330 

Menthol, very useful, 425 

Thyroid gland, gr. 5 (0.3) in early morning, 
followed by quiet and. if possible, by 
sleep, sometimes relieves, 514 

WARTS. 

Acetic and salicylic acids combined, 70 
Chromic acid (gr. 100 to the ounce [6.6 : 

30.0]), locally applied, to remove, 212 
Fowler's solution, locally applied, 119 
Glacial acetic acid, useful to remove, 60 
Mercuric nitrate solution, locally, 376 
Nitric acid as a caustic, 390 
Sulphuric acid, locally, 498 
Trichloracetic acid, useful, 515 

WHOOPING-COUGH, 942 

Amber, oil of, 89 

Amyl nitrite, when paroxysms interfere 
with respiration, 98, 942 

Antipyrine, gr. | to 3 (0.03-0.2) every 
five hours, probably the best remedy, 
107, 942 

Belladonna, tincture of, T([ 2 (0.12) twice 
a day, to child of one or two years, 142, 
942 

Benzine, 942 

Bromoform, prescription for, 158, 942 

Bronchitis-tent to modify severity of at- 
tacks, 943 

Carburetted hydrogen, 942 

Chloral, 190 

Chloride of gold and sodium have been 
recommended, 296 

Chloroform, a few whiffs, if paroxysms in- 
terfere with respiration, 203, 942 - 

Creosote, on wet cloths hung in the nursery, 
of value, 247, 602 



INDEX OF DISEASES AND REMEDIES. 



1023 



Gelsemium, 291 

Hyoscyamus. probably better than bella- 
donna, 311 

Milk, in small amounts, may overcome 
vomiting following paroxysms, 942 

Monobromated camphor, 174 

Potassium bromide in, 154 

Quinine (gr. 1 to the ounce [0.06 : 30.0]), in 
spray, useful; also of service in exposed 
children as a prophylactic. 220, 942 

Resorcinol, Tfl. 10 (0.6) of a 2 per cent, 
solution, internally, or, better, in spray. 
459 

Silver nitrate (gr. § to 1 to the ounce [0.03- 
0.06 : 30.0)), in spray, used when stom- 
ach is empty, 389 

Zinc oxide, 533 

WORMS, 943 

Aspidium, very efficient against tape- 
worms, prescription for. 133, 944 

Azedarach, a useful remedy against round- 
worms, 136 

Brayera, as an infusion, or fluidextract, 
against round-worms. 250, 943 

Calomel, should follow or precede all drugs 
used for tape-worms, 944 

Castor oil, or a saline purgative, should 
follow remedies for round-worms, 943 

Chenopodium, oil of, 1T\ 5 to 20 (0.3-1.3), 
on sugar, to remove round-worms, 186 

Chloroform should not be used against 
tape-worms, 208 

Cusso in tape-worms. 250. 943 

Kamala, drachms 1 to 2 (4.0-8.0), in syrup, 
against tape-worms, 341 

Koosin, gr. 40 (2.6), to adult, against 
round-worms, contraindicated in preg- 
nant women, 250, 943 

Matricaria, 360 

Pelletierine, gr. 3 to 5 (0.2-0.3), in cap- 
sule, best remedv against tape- worm, 
449, 944 

Pepo, ounce 2 (60.0). in confection against 
tape- worm, 423, 944 

Pomegranate, useful in tape-worm, 449. 944 

Quassia injections, preceded by soap and 
water, most useful remedy against seat- 
worms, 457, 944 

Rue, shouid not be used against round- 
worms, 462 

Rules for diet preceding taeniacides. 943 

Salicylic acid, gr. 8 (0.5) hourly, till gr. 40 
(2.6) are taken, against round-worms, 
or as an injection against seat- worms, 
prescription for, 467 

Santonin, gr. | to \ (0.015-0.03). in troches 
for child, against round-worms, 472, 943 



Spigelia, alone or, better, with senna, to 
remove round-worms, 488, 943 

Thymol, gr. 2 to 4 (0.12-0.25), in capsule, 
once a day, for removal of anchylostoma 
duodenaie and in uncinariasis, 511, 944 

Turpentine and castor oil, equal parts, effi- 
cient, but somewhat dangerous, against 
tape-worm, 525 

WOUNDS. 

Acetanilid as a dusting-powder, 67 
Aicohol, very useful in contused wounds. 

78 
Castor oil, with a few drops of balsam of 

Peru or oil of eucalyptus, excellent, 184 
Chloretone, with equal parts boric acid, as 

an antiseptic dressing. 193 
Collodion as an air-tight dressing for small 

wounds. 238 
Dakin's fluid, 539 
Dichloramine-T, the best wound dressing 

we have, 542 
Formidine as a dusting-powder, 286 
Glutol as an antiseptic powder. 288 
Hydrogen peroxide, a valuable cleansing 

preparation in infected wounds, 310 
Iodine, tincture, painted in wounds filled 

with dirt as an antiseptic, 323 
Iodol collodion, useful. 328 
Magnesium sulphate, saturated solution. 

an excellent dressing for wounds infected 

with streptococci, 358 
Oil of cinnamon, 224 
Orthoform as an antiseptic, 418 
Potassium permanganate (gr. 20 to 60 to 

the pint [1.3-4.0 : 480.0]), as an antisep- 
tic wash, 427 
Salicylic acid, 467 
Sozoiodol as an antiseptic and disinfectant 

in diseased wounds, 487 
Thymol, locally, 511 
XJrotropin, useful in traumatisms of brain 

and cord to prevent infection, 301 
Xeroform, 531 



XANTHOMA. 

Carbon dioxide snow. 556 

YAWS. 

Arsphenamine (salvarsan), a specific. 127 

YELLOW FEVER. 

Cocaine of great value as a stimulant and 
auti-emetic, 231 






OCT -0 I9M 



